Antipsychotics in the Management of Disruptive Behavior Disorders in Children and Adolescents: An Update and Critical Review

On- and Off-Label Atypical Antipsychotic Prescription Trends Across a Nine-Year Period Among Adolescents Pre- to Post-COVID-19

OBJECTIVE

This study examined atypical antipsychotic prescribing by Food and Drug Administration (FDA) approved-use (on-label) status for adolescents before and during the COVID-19 pandemic.

METHODS

Retrospective data were collected from electronic health records (EHRs) of adolescents aged 10-17 years in Kaiser Permanente Northern California. New outpatient atypical antipsychotic prescription orders during 2013-2021 were evaluated. Prescriptions were categorized as on-label if linked in EHRs to autism, psychosis, bipolar disorder, or Tourette's diagnoses; otherwise, they were potentially off-label (herein, off-label). Trend analysis of monthly prescribing rates assessed slope change at pandemic onset for the cohort and by sex and age groups.

RESULTS

Among 5828 patients, 74.5% of new antipsychotic orders were off-label in 2021. Overall prescribing decreased significantly until early 2020 (slope = -0.045, P < .01) but then significantly increased through 2021 (post-March 2020 slope change = 0.211, P = .01). Off-label prescriptions increased at a similar rate during the COVID-19 time period, but on-label prescriptions did not change significantly. Males and younger adolescents (ages 10-14 years) showed significant decreases until early 2020, while females and older adolescents (ages 15-17 years) did not. Females and younger adolescents exhibited significant increases in overall and off-label prescribing rates following pandemic onset; older adolescents exhibited increases in overall prescriptions while males had no detectable changes.

CONCLUSIONS

Antipsychotic prescribing declined slightly but then increased significantly following COVID-19 onset for overall and off-label prescriptions. Pandemic onset differentially impacted antipsychotic prescribing by sex and age, with overall and off-label prescribing driven by increases among female and younger adolescents.

Common pitfalls, and how to avoid them, in child and adolescent psychopharmacology: Part II

As Faculty of the British Association for Psychopharmacology course on child and adolescent psychopharmacology, we present here what we deem are the most common pitfalls, and how to avoid them, in child and adolescent psychopharmacology. In this paper, we specifically addressed common pitfalls in the pharmacological treatment of autism and intellectual disability, eating disorders, neuropsychiatric correlates of epilepsy, and psychosis. Pitfalls in relation to the treatment of other disorders are addressed in a separate paper (Part I).

An expert opinion on the pharmacological interventions for Disruptive Mood Dysregulation Disorder (DMDD)

INTRODUCTION

Disruptive Mood Dysregulation Disorder (DMDD) was officially introduced as a new diagnostic entity in the Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-5), under the category of depressive disorders.

AREAS COVERED

A comprehensive overview and a critical commentary on the currently investigated psychopharmacological approaches for the treatment of DMDD have been here provided.

EXPERT OPINION

Behavioral and psychosocial interventions should be considered as first-line treatment strategies. When ineffective or partially effective, psychopharmacological strategy is recommended. Overall, pharmacological strategy should be preferred in those individuals with psychiatric comorbidities (e.g. ADHD). Indeed, so far published studies on pharmacological strategies in DMDD are scant and heterogeneous (i.e. age, assessment tools, symptomatology profile, comorbidity, and so forth). Therefore, DMDD psychopharmacological guidelines are needed, particularly to guide clinicians toward the patient's typical symptom profile who could benefit from psychopharmacological strategy.

Contemporary diagnosis and treatment of conduct disorder in youth

INTRODUCTION

Conduct disorder (CD) is characterized by repetitive and persistent antisocial behaviors, being among the most frequently reported reasons of referral in youth. CD is a highly heterogeneous disorder, with possible specifiers defined according to age at onset, Limited Prosocial Emotions (LPE) otherwise known as Callous-Unemotional (CU) traits, Emotional Dysregulation (ED), and patterns of comorbidity, each with its own specific developmental trajectories.

AREAS COVERED

The authors review the evidence from published literature on the clinical presentations, diagnostic procedures, psychotherapeutic and psychoeducational approaches, and pharmacological interventions from RCT and naturalistic studies in youth. Evidence from studies including youths with LPE/CU traits, ED and aggression are also reviewed, as response moderators.

EXPERT OPINION

Due to its clinical heterogeneity, relevant subtypes of CD should be carefully characterized to gain reliable information on prognosis and treatments. Thus, disentangling this broad category in subtypes is crucial as a first step in diagnosis. Psychosocial interventions are the first option, possibly improving LPE/CU traits and ED, especially if implemented early during development. Instead, limited information, based on low-quality studies, supports pharmacological options. Second-generation antipsychotics, mood stabilizers, and stimulants are first-line medications, according to different target symptoms, such as aggression and emotional reactivity. Developmental pathways including ADHD suggest a specific role of psychostimulants.

Clinical review: Implementation of trauma informed care to optimally impact the treatment of childhood obesity

Background

Traumatic events that occur in infancy, childhood, and adolescence can be impactful over the course of a lifespan. Adverse childhood experiences (ACEs) are associated with chronic health problems and mental illness, and can negatively impact educational and job opportunities. There is a growing body of evidence about the relationship between ACEs and the risk of childhood obesity. Trauma informed care (TIC) is an approach to patient care both at the clinical and organizational level that is responsive to the impact past trauma can have on an individual.

Methods

This clinical review will focus on the impact of toxic stress from trauma on the child through threats to normal physiology, including the manifestation of obesity through energy regulation pathophysiology, followed by a discussion of TIC principles. Available resources and how trauma informed principles can be used in practice are discussed using case study methodology.

Results

TIC programs recognize the impact of trauma on both patients and clinicians. TIC implementation includes application of TIC four assumptions and six key principles out-lined by Substance Abuse and Mental Health Services Administration's guidance. Clinicians supported by well-designed systems recognize that disclosure is not the goal of TIC; instead, broad trauma inquiry, proceeding to risk and safety assessment if indicated, and connection to interventions is the focus. Best practice communication allows clinicians to access information without retraumatizing the patient with ongoing repetition of their trauma experience.

Conclusion

Combining the pillars of obesity treatment (i.e., nutrition, physical activity, behavior therapy, medical management) with the tenets of TIC (realize, recognize, respond, resist re-traumatization) affords patients holistic, intentional care and family support. The desired outcomes of TIC align with goals of obesity treatment in children, namely improvement of health and quality of life, sense of self (e.g., body image and self-esteem), and prevention of negative health outcomes.