Medication patterns for attention-deficit/hyperactivity disorder and comorbid psychiatric conditions in a low-income population

The aims of this study were two-fold: (1) to describe the patterns of comorbid psychiatric diagnosis and psychotropic drug therapy for children enrolled in a Medicaid-managed care program and diagnosed with attention-deficit/hyperactivity disorder (ADHD) in 2000 and (2) to examine child and provider characteristics associated with psychotropic medication patterns for this population. Multivariate logistic regression models were used to examine correlates of stimulant and seven nonstimulant psychotropic medication classes (alpha-agonists, mood stabilizer/anticonvulsant, antianxiety, standard antipsychotic, atypical antipsychotic, and tricyclic antidepressant (TCA)/other antidepressant and selective serotonin reuptake inhibitor (SSRI) antidepressant). With the exception of conduct disorders (odds ratio, 1.22; 95% confidence interval, 1.06-1.40), comorbid disorders had a significant protective effect (odds ratio less than 1) on dispensing stimulants. After adjusting for covariates, stimulant dispensing was strongly correlated with the interactions of geographic region with race/ethnicity and provider type. Children residing in the upstate New York region had an approximately ten-fold greater chance of being dispensed a stimulant compared to similar children in New York City. Utilizing a mental health provider increased the chance of being dispensed a stimulant by factor of two for children from New York City of any race/ethnicity group. Models predicting nonstimulant drug dispensing were distinct from the stimulant model. After adjusting for covariates, nonstimulant psychotropic medication dispensing was correlated with clinical factors, including comorbid disorder category and use of a mental health provider, as well as notable sociodemographic factors. Complex psychotropic medication and comorbid psychiatric disorder patterns were evident for this low-income population of children with ADHD. The roles of clinical, patient, and provider factors need to be better understood to explain these patterns of stimulant and nonstimulant psychotropic medications dispensed.     

Polypharmacy profiles and predictors among adults with autism spectrum disorders

Pharmacological interventions are frequently used to treat commonly associated mental health and behavioural issues in individuals with autism spectrum disorders (ASD). Despite high rates of psychotropic drug use documented in children with ASD, very few studies have examined medication profiles, side effects, and rates of polypharmacy in adolescents and adults with ASD. To address this, we examined medication profiles and predictors of polypharmacy among 142 adults with ASD who had experienced a psychiatric crisis. Of the 142 adults sampled, 91 (64.1%) were prescribed at least 1 psychotropic medication and 41 (28.9%) were taking 3 or more psychotropic medications. Variables associated with and predictive of polypharmacy included history of aggression, residence, and psychiatric support. Adults with ASD are a highly medicated population and polypharmacy is a significant concern in this vulnerable group of individuals.     

Perinatal psychotropic dispensing: A descriptive population-based study in New Zealand

Introduction

Decisions about using psychotropics during pregnancy are complex as risks of untreated illness are balanced against risks of fetal exposure to medication. The objective was to describe perinatal psychotropic dispensing patterns in New Zealand.

Methods

Nationwide data from the New Zealand National Maternity Collection between January 1, 2011 and December 31, 2017 identified 399 715 pregnancies. These were linked with dispensing records to determine the proportion of pregnancies during which at least 1 psychotropic was dispensed. Proportions were calculated separately for each class, year, pregnancy period, and across maternal characteristics. The pattern of dispensing (including discontinuations) was also determined for the 25 841 women who were dispensed at least 1 psychotropic drug prior to pregnancy.

Results

From the 399 715 pregnancies in the study cohort, 6.6% were dispensed at least 1 psychotropic during pregnancy. Antidepressants (5.1%) were the most dispensed, followed by hypnotics (1.2%), anxiolytics (0.7%), and antipsychotics (0.7%). From the 25 841 pregnancies during which a psychotropic was dispensed pre-pregnancy, 91% and 90% discontinued hypnotics and anxiolytics respectively, prior to or during pregnancy. This was followed by lithium (71%), antipsychotics (66%), and antidepressants (66%).

Discussion

Dispensing of psychotropics during pregnancy occurs in approximately 6.6% of pregnancies in New Zealand. Two-thirds of women (66%) on antidepressants or antipsychotics discontinue dispensing before or during pregnancy. This may have implications for maternal mental health, suggesting there is a need to investigate how healthcare providers and women are making decisions about psychotropic use during pregnancy.     

Sleep hygiene and melatonin treatment for children and adolescents with ADHD and initial insomnia

OBJECTIVE: To evaluate the efficacy of sleep hygiene and melatonin treatment for initial insomnia in children with attention-deficit/hyperactivity disorder (ADHD). METHOD: Twenty-seven stimulant-treated children (6-14 years of age) with ADHD and initial insomnia (>60 minutes) received sleep hygiene intervention. Nonresponders were randomized to a 30-day double-blind, placebo-controlled, crossover trial of 5-mg pharmaceutical-grade melatonin provided by the study's sponsor. RESULTS: Sleep hygiene reduced initial insomnia to <60 minutes in 5 cases, with an overall effect size in the group as a whole of 0.67. Analysis of the trial data able to be evaluated showed a significant reduction in initial insomnia of 16 minutes with melatonin relative to placebo, with an effect size of 0.6. Adverse events were generally mild and not different from those recorded with placebo treatment. The effect size of the combined sleep hygiene and melatonin intervention from baseline to 90 days' posttrial was 1.7, with a mean decrease in initial insomnia of 60 minutes. Improved sleep had no demonstrable effect on ADHD symptoms. CONCLUSION: Combined sleep hygiene and melatonin was a safe and effective treatment for initial insomnia in children with ADHD taking stimulant medication.     

Melatonin for insomnia in children with autism spectrum disorders

We describe our experience in using melatonin to treat insomnia, a common sleep concern, in children with autism spectrum disorders. One hundred seven children (2-18 years of age) with a confirmed diagnosis of autism spectrum disorders who received melatonin were identified by reviewing the electronic medical records of a single pediatrician. All parents were counseled on sleep hygiene techniques. Clinical response to melatonin, based on parental report, was categorized as (1) sleep no longer a concern, (2) improved sleep but continued parental concerns, (3) sleep continues to be a major concern, and (4) worsened sleep. The melatonin dose varied from 0.75 to 6 mg. After initiation of melatonin, parents of 27 children (25%) no longer reported sleep concerns at follow-up visits. Parents of 64 children (60%) reported improved sleep, although continued to have concerns regarding sleep. Parents of 14 children (13%) continued to report sleep problems as a major concern, with only 1 child having worse sleep after starting melatonin (1%), and 1 child having undetermined response (1%). Only 3 children had mild side-effects after starting melatonin, which included morning sleepiness and increased enuresis. There was no reported increase in seizures after starting melatonin in children with pre-existing epilepsy and no new-onset seizures. The majority of children were taking psychotropic medications. Melatonin appears to be a safe and well-tolerated treatment for insomnia in children with autism spectrum disorders. Controlled trials to determine efficacy appear warranted.     

Melatonin in Children with Autism Spectrum Disorders: Endogenous and Pharmacokinetic Profiles in Relation to Sleep

Supplemental melatonin has been used to treat sleep onset insomnia in children with autism spectrum disorders (ASD), although the mechanism of action is uncertain. We assessed endogenous and supplemental melatonin profiles in relation to sleep in nine children with ASD. In endogenous samples, maximal melatonin concentration (C _max) and time to peak concentration (T _max) were comparable to those previously published in the literature for typically developing children, and dim light melatonin onsets were captured in the majority of children. In treatment samples (supplemental melatonin), melatonin parameters were also comparable to those previously published for typically developing children. Our findings support that children with ASD and insomnia responsive to low dose melatonin treatment have relatively normal profiles of endogenous and supplemental melatonin.     

Psychotropic medication utilization in a child and adolescent mental health service

OBJECTIVES: This study aimed to identify rates and correlates of psychotropic drug utilization in children and adolescents in inpatient and outpatient settings. METHODS: A retrospective chart review examined 122 inpatient and 126 outpatient charts from a metropolitan child and youth mental health service in Brisbane, Australia. RESULTS: Inpatients received more psychotropic medication than outpatients (71% vs. 25%; p < 0.01). Patients receiving medication were older, had longer hospital admissions, and more complex presentations, including history of abuse or suicide attempts and more diagnoses (all p < 0.01). Selective serotonin reuptake inhibitors (SSRIs) were the most frequently used drug class (44% inpatients; 14% outpatients), primarily indicated for mood disorders (31%). SSRIs and newer antidepressants (ADs) were used more frequently in patients with a high suicide risk (p < 0.01). Atypical antipsychotics (APs) were also used (inpatients 23%; outpatients 3%), primarily for behavioral disturbances. Half of those receiving medication (51%) received polypharmacy (>1 concurrent drug), with up to four drugs used at one time. Rates of polypharmacy were highest among patients receiving antipsychotics. CONCLUSIONS: Use of psychotropic medication is frequent in this population. Future research should initially focus on inpatients and intensive treatment settings and examine both safety and efficacy of interventions for depression in young people, atypical antipsychotics for behavioral disturbances, and polypharmacy.     

Rates of psychotropic medication use in children with ASD compared to presence and severity of problem behaviors

There is a scarcity of research on the relationship between presence of problem behaviors and psychotropic medication use in children with autism spectrum disorder (ASD). Participants in the current study were children and adolescents ages 3–17 years who were sorted into four groups: ASD on psychotropic medication (N = 100), ASD not on psychotropic medication (N = 147), typically developing on medication (N = 48), and typically developing not on medication (N = 168). A one-way multivariate analysis of covariance (MANCOVA) was conducted to determine the relationship between medication use and rates of internalizing and externalizing behaviors. Post hoc analyses revealed that children with ASD on psychotropic medication evinced significantly more externalizing behaviors than children with ASD not on medication. However, the two groups did not significantly differ on rates of internalizing behaviors. These results suggest that psychotropic medications may often be prescribed to manage externalizing behaviors. Implications of these findings are discussed in relation to the existing literature.     

Parent-reported symptoms,impairment, helpfulness of treatment,and unmet service needs in a follow-up of outpatient children with attention-deficit/hyperactivity disorder

Background: Limited information exists regarding the associations between impairment, symptoms, helpfulness of treatments, and service needs after initial treatment of children with attention-deficit/hyperactivity disorder (ADHD). Aims: The aims of this study were to examine persistence rates and associations between parent-reported symptoms, impairment, helpfulness of treatments, and service needs in a retrospective follow-up study of children with ADHD.

Methods: Parents of 214 children with a mean age of 12.6 years (SD?=?2.1) who were diagnosed with ADHD at five child and adolescent mental health clinics (CAMHS) completed questionnaires 1–10 years (mean?=?3.7 years, SD?=?2.2) after baseline assessment. The response rate was 43.4%. A community comparison group (n?=?110) was recruited from the same area.

Results: Approximately two-thirds (60.3%) of the sample fulfilled the DSM-IV symptom criteria of ADHD at follow-up, 84.3% were functionally impaired, and most children (84.7%) were on medication. Inattentive and emotional symptoms were the strongest predictors of impairment across impairment areas. Perceived helpfulness of different treatments varied from 71.8–88.7%, and no significant difference was found between the ADHD sub-groups regarding reported helpfulness. ‘Adjustment of the school situation’ was the most frequent service need, and approximately half of the parents reported needs for care co-ordination. Children fulfilling the symptom criteria of the ADHD Combined sub-group were most impaired and had most service needs.

Conclusions: At follow-up, children were highly symptomatic and impaired, despite a high rate of persistent medication treatment. The findings underline the need for more tailored treatment and co-ordinated care over time.     

Do hyperactivity,impulsivity and inattention have an impact on the ability of facial affect recognition in children with autism and ADHD?

Psychopathological, genetic and neuropsychological findings indicate an association between autism and attention deficit/hyperactivity disorder (ADHD). The goal of this study was to assess possible differences in facial affect recognition in children with autism (with and without comorbid ADHD), with ADHD and healthy controls. Children aged 6–18 years old with DSM-IV-diagnosis ADHD (n = 30) or autism (n = 40) were included consecutively in the study. Facial affect recognition was assessed with a computer-based program used for teaching emotion processing called the Frankfurt Test and Training of Social Affect (FEFA) using faces and eye-pairs as target material. Additionally three attention-tasks (Sustained attention, Inhibition, Set-Shifting) were administered. Approximately 52% of the autistic children met the criteria for the comorbid diagnosis of ADHD. A MANOVA with post-hoc Scheffé tests revealed a significant difference in the recognition of faces and eye pairs between the group ADHD and controls (P = 0.009). Children with autism and ADHD also differed significantly from healthy participants in the recognition of eye-pairs (P = 0.009). Neither correlations with PDD nor with ADHD symptom scores were able to explain these results. Sustained attention and inhibition deficits had a significant influence on emotion recognition in children with ADHD. Our findings imply that the ability of facial affect recognition is reduced in children suffering from ADHD symptoms, both in autistic and pure ADHD children. ADHD symptoms need to be taken into account in future studies assessing emotion recognition in autistic children and adolescents. Supported by the Koeln Fortune Program/Faculty of Medicine, University of Cologne     

Multimodal treatment in children and adolescents with attention-deficit/hyperactivity disorder: a 6-month follow-up

Background: Different treatment approaches aimed at reducing attention-deficit/hyperactivity disorder (ADHD) core symptoms are available. However, factors such as intolerance, side-effects, lack of efficacy, high new technology costs, and placebo effect have spurred on an increasing interest in alternative or complementary treatment.

Aim: The aim of this study is to explore efficacy of multimodal treatment consisting of standard stimulant medication (methylphenidate) and neurofeedback (NF) in combination, and to compare it with the single treatment in 6-month follow-up in ADHD children and adolescents.

Methods: This randomized controlled trial with 6-month follow-up comprised three treatment arms: multimodal treatment (NF?+?MED), MED alone, and NF alone. A total of 130 ADHD children/adolescents participated, and 62% completed the study. ADHD core symptoms were recorded pre-/post-treatment, using parents’ and teachers’ forms taken from Barkley’s Defiant Children: A Clinician’s Manual for Assessment and Parent Training, and a self-report questionnaire.

Results: Significant ADHD core symptom improvements were reported 6 months after treatment completion by parents, teachers, and participants in all three groups, with marked improvement in inattention in all groups. However, no significant improvements in hyperactivity or academic performance were reported by teachers or self-reported by children/adolescents, respectively, in the three groups. Changes obtained with multimodal treatment at 6-month follow-up were comparable to those with single medication treatment, as reported by all participants.

Conclusions: Multimodal treatment using combined stimulant medication and NF showed 6-month efficacy in ADHD treatment. More research is needed to explore whether multimodal treatment is suitable for ADHD children and adolescents who showed a poor response to single medication treatment, and for those who want to reduce the use of stimulant medication.