Clinical predictors of antipsychotic use in children and adolescents with autism spectrum disorders: a historical open cohort study using electronic health records

Children with autism spectrum disorders (ASD) are more likely to receive antipsychotics than any other psychopharmacological medication, yet the psychiatric disorders and symptoms associated with treatment are unclear. We aimed to determine the predictors of antipsychotic use in children with ASD receiving psychiatric care. The sample consisted of 3482 children aged 3–17 with an ICD-10 diagnosis of ASD referred to mental health services between 2008 and 2013. Antipsychotic use outcome, comorbid diagnoses, and other clinical covariates, including challenging behaviours were extracted from anonymised patient records. Of the 3482 children (79 % male) with ASD, 348 (10 %) received antipsychotic medication. The fully adjusted model indicated that comorbid diagnoses including hyperkinetic (OR 1.44, 95 %CI 1.01–2.06), psychotic (5.71, 3.3–10.6), depressive (2.36, 1.37–4.09), obsessive–compulsive (2.31, 1.16–4.61) and tic disorders (2.76, 1.09–6.95) were associated with antipsychotic use. In addition, clinician-rated levels of aggression, self-injurious behaviours, reduced adaptive function, and overall parental concern for their child’s presenting symptoms were significant risk factors for later antipsychotic use. In ASD, a number of comorbid psychiatric disorders are independent predictors for antipsychotic treatment, even after adjustment for familial, socio-demographic and individual factors. As current trial evidence excludes children with comorbidity, more pragmatic randomised controlled trials with long-term drug monitoring are needed.     

Constipation prevalence and perceptions: Comparison of children and adolescents with ASD and other developmental-behavioral disorders

BackgroundFew studies have compared youth constipation in autism spectrum disorder (ASD) to constipation in other developmental-behavioral (DB) disorders.MethodsChildren and caregivers presenting to a DB pediatrics and psychology clinic completed written questionnaires on constipation. Comparison groups were ASD vs without ASD and caregiver vs child responses. Binary logistic regression were conducted to compare categorical variables.ResultsCaregivers of 169 toilet trained children and 26 non-toilet trained children completed the survey; 30 % of the toilet trained and 62 % of the non-toilet trained children had ASD. 88 toilet trained children completed the survey. Based on caregiver response, toilet trained youth with ASD were more likely to have been constipated in the past and to currently or previously taken medication to manage constipation. In both the total toilet trained and non-toilet trained sample, more caregivers endorsed their child meeting Rome IV criteria for functional constipation than endorsed current constipation. 37 % of parent/child pairs disagreed on whether the child met the Rome IV criteria. Caregivers of toilet trained youth with ASD were more likely to endorse specific barriers and impairment due to managing constipation in comparison to caregivers of youth without ASD.ConclusionsChildren with ASD may be at a higher lifetime risk of constipation and of needing medication compared to children with other DB disorders. Providers should use thorough questions to identify constipation and gather information from both caregiver and child when possible. Clinicians should consider targeting behavioral treatment recommendations to perceived caregiver concerns.     

Preliminary study of family accommodation in youth with autism spectrum disorders and anxiety: Incidence,clinical correlates,and behavioral treatment response

Anxiety symptoms are common in youth with autism spectrum disorders (ASD) and directly associated with symptom severity and functional impairment. Family accommodation occurs frequently among individuals with obsessive-compulsive and anxiety disorders; to date, no data exist on the nature and correlates of family accommodation in youth with ASD and anxiety, as well as its relationship to cognitive-behavioral therapy outcome. Forty children with ASD and a comorbid anxiety disorder participated. Clinicians administered measures of ASD and anxiety disorder caseness, anxiety symptom severity, and family accommodation; parents completed questionnaires assessing social responsiveness, internalizing and externalizing behaviors, and functional impairment. A subsample of youth (n = 24) completed a course of cognitive-behavioral therapy. Family accommodation was common and positively correlated with anxiety symptom severity, but not functional impairment, general internalizing symptoms, externalizing behavior, or social responsiveness. Family accommodation decreased following cognitive-behavioral therapy with decreases in family accommodation being associated with decreases in anxiety levels. Treatment responders reported lower family accommodation frequency and lower parent impact relative to non-responders. Clinical implications of this study in assessing and psychotherapeutically treating youth with ASD and comorbid anxiety are discussed.     

The Phenomenology and Clinical Correlates of Suicidal Thoughts and Behaviors in Youth with Autism Spectrum Disorders

This study investigated the phenomenology and clinical correlates of suicidal thoughts and behaviors in youth with ASD (N = 102; range 7–16 years). The presence of suicidal thoughts and behavior was assessed through the Anxiety Disorders Interview Schedule-Child and Parent Versions. Children and parents completed measures of anxiety severity, functional impairment, and behavioral and emotional problems. Approximately 11 % of youth displayed suicidal thoughts and behaviors. Children with autism were more likely to have suicidal thoughts and behaviors whereas children with Asperger’s disorder were less likely. Suicidal thoughts and behaviors were associated with the presence of depression and post-traumatic stress disorder. Overall, results suggest that suicidal thoughts and behaviors are common in youth with ASD, and may be related to depression and trauma.     

Anxiety Disorders in Typically Developing Youth: Autism Spectrum Symptoms as a Predictor of Cognitive-Behavioral Treatment

Symptoms of autism spectrum disorder (ASD) were assessed (Social Responsiveness Scale-Parent (SRS-P); coded in-session behavior) in typically-developing, anxiety-disordered children (N = 50) treated with cognitive-behavioral therapy (CBT). Study 1: children with moderate autistic symptomology (per SRS-P) were significantly more likely to improve from family CBT (FCBT) than individual CBT (ICBT; OR = 8.67). Coded behavior did not predict outcome. Study 2: CBT components were compared by treatment and ASD symptom status. At-home exposure completion was greater in FCBT and there was an interaction in child involvement for treatment and ASD status. Though both treatments reduced anxiety, FCBT outperformed ICBT for children with moderate ASD symptoms, a benefit potentially linked to more at-home exposures and greater child involvement in FCBT.     

Medical Conditions and Demographic,Service and Clinical Factors Associated with Atypical Antipsychotic Medication Use Among Children with An Autism Spectrum Disorder

This study aimed to describe rates of antipsychotic medication use and the association between their use and demographics, clinical variables, and the use of behavioral/education services among children with ASD. For children with ASD ages 2–11 (n?=?4749) and those 12–17 (n?=?401), 5.4 and 17.7% were prescribed at least one atypical antipsychotic medication respectively. In the multivariable model of young children, older age, use of multiple psychotropic medications, prior ASD diagnosis, non-white Hispanic race/ethnicity, and oppositional defiant problems were associated with antipsychotic use. Among older children, only older age was associated with antipsychotic use. In at least one age group, antipsychotic medication use was also related to behaviour, family and occupational therapy, public insurance, site region, externalizing problems, body mass index, and sleep and gastrointestinal problems.     

The relationship of comorbid anxiety symptom severity and challenging behaviors in infants and toddlers with autism spectrum disorder

The rates of comorbid anxiety as well as the presentation of challenging behaviors are elevated within the autism spectrum disorder (ASD) population. The current study utilizes the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT) to explore the relationship of anxiety/repetitive behavior symptom severity and challenging behaviors in infants and toddlers with ASD. Children with ASD who evinced more severe impairment associated with anxiety/repetitive behavior (n = 94) demonstrated higher rates of overall challenging behaviors than those with ASD who evinced no to minimal anxiety impairment (n = 291). Specifically, a comparison of individual challenging behavior items indicated that the infants and toddlers with moderate to severe anxiety impairment exhibited more significant challenging behaviors under the domains of aggression/destruction, stereotypies, and self-injurious behavior than children with no to minimal impairment. This study adds to the literature evidencing an exacerbation of challenging behaviors by comorbid psychopathology in individuals with ASD. Clinical implications of these results are discussed.     

A comparison of children and adolescents with ASD,atypical development,and typical development on the Behavioral Assessment System for Children,Second Edition (BASC-2)

The present study examined the use of the Behavioral Assessment System for Children, Second Edition (BASC-2) in discerning 151 children and adolescents 12–16 years of age with autism spectrum disorder (ASD) from atypically and typically developing children and adolescents. Scores on the BASC-2 composites (i.e., externalizing behaviors, internalizing behaviors, behavior symptom index [BSI], adaptive behaviors) and subscales (i.e., hyperactivity, aggression, conduct problems, anxiety, depression, somatization, atypicality, withdrawal, attention, adaptability, social skills, leadership, activities of daily living, functional communication) were compared between children and adolescents with ASD, atypical development, and typical development. With the exception of aggression, somatization, and internalizing behaviors, participants with ASD were significantly more impaired than typically developing participants in all other composites and subscales. In comparison to atypically developing participants, the scores of participants with ASD evinced more impairment for BSI and its subscales, with the exception of attention, and the adaptive behavior composite and its subscales, with the exception of adaptability. Scores on the externalizing behaviors and internalizing behaviors composites and their subscales, with the exception of anxiety, were not significantly different. Research and clinical implications are discussed.     

Psychiatric treatment in primary care patients with anxiety disorders: a comparison of care received from primary care providers and psychiatrists

OBJECTIVE: This study examined psychiatric treatment received by primary care patients with anxiety disorders and compared treatment received from primary care physicians and from psychiatrists. METHOD: Primary care patients at 15 sites were screened for anxiety symptoms. Those screening positive were interviewed to assess for anxiety disorders. Information on psychiatric treatment received and provider of pharmacological treatment were collected. RESULTS: Of 539 primary care participants with at least one anxiety disorder, almost half (47.3%) were untreated. Nearly 21% were receiving medication only for psychiatric problems, 7.2% were receiving psychotherapy alone, and 24.5% were receiving both medication and psychotherapy. Patients receiving psychopharmacological treatment received similar medications, often at similar dosages, regardless of whether their prescriber was a primary care physician or a psychiatrist. One exception was that patients were less likely to be taking benzodiazepines if their provider was a primary care physician. Those receiving medications from a primary care provider were also less likely to be receiving psychotherapy. Overall, patients with more functional impairment, more severe symptoms, and comorbid major depression were more likely to receive mental health treatment. Members of racial/ethnic minority groups were less likely to be treated. Frequently endorsed reasons for not receiving pharmacological treatment were that the primary care physician did not recommend it and the patient did not believe in taking medication for emotional problems. CONCLUSIONS: Nearly half the primary care patients with anxiety disorders were not treated. However, when they were treated, the care received from primary care physicians and psychiatrists was relatively similar.     

Family Contact and the Management of Medication Non-adherence in Schizophrenia

We compare psychiatric management of antipsychotic non-adherence among schizophrenia outpatients with high and low levels of family contact. A national survey was conducted among a random sample of psychiatrists treating schizophrenia, providing data on 310 patients. Patients were stratified by level of family contact. Psychiatrists were more likely to use family interventions to manage non-adherence among patients with high family contact. Psychiatrists were significantly more likely to change antipsychotic dosing in patients with high family contact, though less likely to start depot antipsychotic medications. Family interventions appear to be commonly used in the psychiatric management of medication non-adherence in schizophrenia.     

Substance abuse and the management of medication nonadherence in schizophrenia

To compare the clinical characteristics and psychiatric management of antipsychotic nonadherence among outpatients with schizophrenia who either do or do not have current or past comorbid substance use disorders, a national survey was conducted of psychiatrists engaged in the management of schizophrenia. Respondents reported on the presentation and management of one adult patient who had been under their care for at least 1 year and who had been nonadherent with oral antipsychotic medications at some point in the last year. The response rate was 69.3%. Patients with schizophrenia only (N = 190) were compared with patients with schizophrenia and a history of a co-occurring substance use disorder (N = 105). Approximately one third (35.6%) of antipsychotic nonadherent schizophrenia patients had a comorbid substance use disorder. Denial of illness was the most commonly cited primary reason for antipsychotic nonadherence. Psychiatrists were significantly less likely to discuss with comorbid patients than patients without comorbid substance use linkages between antipsychotic adherence and progress toward personal goals (64.5% vs. 78.9%), and significantly less likely to explore the meaning of taking medication to the patient's identity (59.2% vs. 73.3%). However, psychiatrists were approximately two times more likely to add another antipsychotic for patients with substance use disorders (22.8% vs. 11.0%). There were no perceived differences between the two groups in effectiveness of interventions to manage medication nonadherence. Comorbid substance use disorders are common among psychiatric outpatients with schizophrenia who are nonadherent with antipsychotic medications. Some psychological approaches tend to be used less often with patients with comorbid substance use disorders, although when they are used, psychiatrists report they are no less effective than they are for schizophrenia patients without comorbid substance use disorders. These findings suggest that some psychological interventions may tend to be underutilized in the management of medication nonadherence among patients with comorbid schizophrenia and substance use disorders.     

Brief Report: Atypical Social Cognition and Social Behaviours in Autism Spectrum Disorder: A Different Way of Processing Rather than an Impairment

A central question to autism research is whether autism is largely the result of an impairment in social cognition and/or motivation or the result of a more general processing difference. This review discusses problems with the “social deficit” model of autism spectrum disorder (ASD). It is suggested that superior attention to low-level perceptual information potentially coupled with decreased attention to global information may provide a more comprehensive explanation for atypical social behaviours in ASD. This processing style may reflect increased activation of occipital-temporal regions and reduced functional (and possibly anatomical) connectivity. It is concluded that atypical social behaviours in ASD are more likely to be a consequence reflective of a general processing difference than impairment in social cognition and/or motivation.     

Use of functional analysis methodology in the evaluation of medication effects

The atypical antipsychotic medication risperidone was evaluated using a double-blind, placebo-controlled design in the treatment of destructive behavior in two individuals with autism. Premedication functional analyses indicated that destructive behavior was maintained by escape from demands, attention, or access to tangible items. For both individuals, destructive behavior during the demand condition was significantly reduced during the medication phases, whereas destructive behavior continued to occur to obtain tangible items (Reggie) and attention (Sean). In addition, there appeared to be a differential effect of the medication on self-injurious behavior (SIB) versus aggression for Sean. Results of the study demonstrate how functional analysis may provide information on those conditions and behaviors that are most likely to be affected by a specific medication.     

Sleep, anxiety and challenging behaviour in children with intellectual disability and/or autism spectrum disorder

Children with an intellectual disability (ID) and/or autism spectrum disorder (ASD) are known to suffer from significantly more sleep problems, anxiety and challenging behaviour (CB) than typically developing children (TD), yet little is known about the relationship between these factors in the child ID/ASD population. The study aim was to examine these relationships. We hypothesised that there would be significant positive correlations between the three factors and that sleep problems and anxiety would predict a significant amount of the variance in levels of CB. Parental measures of sleep problems, anxiety and CB were completed by 187 parents of children with ID and/or ASD. Significant positive associations were found between the three factors. A hierarchical multiple regression showed that medication, sleep problems and anxiety accounted for 42% of the variance in CB, with a large effect size. These findings suggest that these relationships should be considered during clinical practice, particularly in the case of CB interventions where sleep problems and/or anxiety are also present.     

Characteristics and anxiety symptom presentation associated with autism spectrum traits in youth with anxiety disorders

There is limited information about the nature of anxiety among youth with symptoms of autism spectrum disorder (ASD). The present study examined (a) differences in the clinical characteristics of anxious youth with and without symptoms of ASD and (b) the symptoms of anxiety that best distinguish between these groups. Results indicated that anxious youth with elevated ASD symptoms had significantly more diagnoses (e.g., specific phobias), and were more likely to meet diagnostic criteria for social phobia (and list social concerns among their top fears) than youth without elevated ASD symptoms. At the symptom level, severity of interpersonal worry based on parent report and severity of fear of medical (doctor/dentist) visits based on youth report best differentiated ASD status. The findings inform diagnostic evaluations, case conceptualization, and treatment planning for youth with anxiety disorders and ASD symptoms.     

The disruptive behavior disorders in the psychiatric emergency service.

Many children and adolescents presenting to the Psychiatric Emergency Service (PES) are diagnosed with the Disruptive Behavior Disorders (DBD), Conduct Disorder (CD), and Oppositional Defiant Disorder (ODD). Sometimes it may be difficult to reliably diagnose these disorders in the PES setting. Given these limitations, a large database of 6 years of PES visits showed 314 patients with DBD compared with 1625 without DBD. More DBD patient visits required the intervention of police and/or the mobile crisis team. These patients are more likely to have additional diagnoses of depression and attention deficit hyperactivity disorder, be in current treatment, or involved with court or the correctional system. They are less frequently referred by other emergency services such as medical ERs. DBD patients do not require emergency medication or psychiatric hospitalization any more frequently than other youngsters presenting to the PES. In the PES setting there is little differentiation between the CD and the ODD population. A more detailed study of the presenting symptomatology of the DBD vs non-DBD patients revealed that DBD patients showed over twice as many disruptive behavior symptoms. Fights and defiance were present significantly more frequently than in controls, with a trend toward increased frequency of bullying and stealing. The clinical and public mental health implications of these findings are discussed.     

Explaining service use for mental health problems in the Dutch general population: the role of resources, emotional disorder and functional impairment

Objective To analyse explanations of service use in terms of resources, emotional (mood or anxiety) disorder and functional impairment. Method Data was derived from a prospective cohort study in a sample representative (n = 4848) of the Dutch adult general population. Results The occurrence of an emotional (mood or anxiety) disorder led to a greater use of services as a partial consequence of the functional impairments that accompanied the disorder, but this applied only to primary care services and not to specialised mental health services. After adjustment for the influence of all other determinants in the model, people with more education and those with higher neuroticism scores were more likely to use specialised services in particular. Conclusions Future research could benefit from applying the models derived here to further clarify the use of the two service modalities, as well as to assess additional psychological resources.     

Antipsychotic dosage at hospital discharge and outcomes among persons with schizophrenia

OBJECTIVE: Applying the schizophrenia treatment guidelines established by the Patient Outcomes Research Team (PORT) project, this study evaluated whether antipsychotic medication dosage influenced patient outcomes in routine clinical settings. METHODS: The associations between discharge antipsychotic medication dosage and short-term clinical, social, and service use outcomes were observed in a sample of 246 patients with schizophrenia or schizoaffective disorder. RESULTS: Patients who were given high dosages of antipsychotic medication at hospital discharge (more than 1,000 chlorpromazine milligram equivalents) had greater severity of symptoms three months after discharge than patients who were given guideline-recommended dosages (300 to 1,000 chlorpromazine milligram equivalents) (adjusted mean Brief Psychiatric Rating Scale scores of 45 and 39, respectively). Patients who were given low dosages of antipsychotic medication at hospital discharge (less than 300 chlorpromazine milligram equivalents) were less likely to report side effects (adjusted OR=.24) and slightly more likely to be nonadherent (21 percent of those within the recommended dose range compared with 39 percent of the those with low doses, not statistically significant after Bonferroni correction). No other differences related to medication dosage were observed in patient outcomes. CONCLUSIONS: Treatment that falls within antipsychotic medication dosage guidelines is associated with improvement in a limited, but critical, range of short-term patient outcomes in routine clinical settings.