AACAP Annual Meeting

SAN ANTONIO– As foreign wars wind down, and more families of military members and veterans receive care in civilian settings, an intervention used successfully on military bases to help families reduce risk of serious psychological disorders is being extended to civilian practices.

In the past decade, some 650,000 military and veteran family members have gone through Families Overcoming Under Stress, or FOCUS, a group of family-based interventions developed by a team led by psychiatrist Dr. Patricia E. Lester, director of the Nathanson Family Resilience Center at UCLA Health in Los Angeles.

Courtesy Anne Allhoff

Dr. Lester and her UCLA colleagues first adapted FOCUS at Marine Corps Base Camp Pendleton, San Diego, in 2006. Two years later, they implemented the program for the U.S. Navy Bureau of Medicine and Surgery at 22 Navy, Marine, Army, and Air Force installations in the United States and overseas. Now, with as many as 70% of active-duty military members living in civilian communities and about half of military-affiliated children getting health care in the civilian system, the program is being adapted to follow veterans’ families as they transition home.

The UCLA FOCUS team also is training community providers and extending technology platforms “to deliver our programs, monitor them, and put them in the hands of people where they live,” Dr. Lester said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

New research from a longitudinal observational study assessing more than 2,600 families with children who participated in the program in the United States and Japan on military bases, published recently online, shows that the intervention has been well received, with about 70% of families completing it. In addition, its positive impact on psychological health outcomes for parents and children was sustained (J Am Acad Child Adolesc Psychiatry. 2015 [doi: http://dx.doi.org/10.1016/j.jaac.2015.10.009]).

“Consistently what we’ve found is that doing a preventive educational program early on is an opportunity to engage families before they may need mental health treatment – reducing anxiety, depression, and [posttraumatic stress disorder] in adults, strengthening family functioning, and improving internalizing and externalizing symptoms in kids,” Dr. Lester said.

The latest research is based on a secondary analysis of FOCUS data collected between 2008 and 2013. Significant improvements for parental anxiety, posttraumatic stress, and depression symptoms occurred in service member and civilian parents, and child anxiety symptoms improved in boys and girls. Importantly, those reductions were maintained 6 months after the intervention ended.

Roots of intervention

The model for FOCUS derives from two civilian interventions developed over the past 15 years, one of them for families in which a parent is depressed, and another for those in which a parent is medically ill. FOCUS also incorporated elements of a third intervention used with families living in postwar Bosnia-Herzegovina and in New York City after the terrorist attacks of Sept.11, 2001.

“We know from decades of developmental literature that if a parent is not doing well in terms of depression, anxiety, or PTSD, it represents an ongoing risk for children,” Dr. Lester said. In military and veteran populations, “family approaches are critical.”

About a third of combat service members and veterans are estimated to have depression, PTSD, or a traumatic brain injury – and an emerging body of research is showing that their children are at elevated risk for social, academic, and emotional problems.

The FOCUS program, which generally lasts 8 sessions over 6-8 weeks, starts with real-time web-based screening of psychological health measures, using a set of standardized behavioral health, family adjustment, and coping assessments to assess risk and customize the intervention. “We sit down with the family; we identify their strengths and where they may be having difficulties,” Dr. Lester said.

About a quarter of the parents in Dr. Lester’s study had clinically meaningful anxiety or depression symptoms at intake, with civilian spouses reporting slightly more than military members. Also, some 31% of civilian spouses had PTSD symptoms at baseline, compared with 26% of military members – an unexpected finding, Dr. Lester said. Among children, 35% of boys and 25% of girls had social difficulties at baseline.

Location of intervention is key

Rolling FOCUS out on military installations required attention to military family culture. A voluntary program, it was implemented to service members as a form of training, rather than counseling or a mental health intervention, though part of its objective was to help to bridge gaps to mental health treatment for those who needed it.

Importantly, the intervention was delivered in community centers or retail spaces in lieu of mental health facilities on bases. “Military families may be reluctant to come for behavioral health services because of stigma or concern about their job – the same barriers we see in civilian communities but amplified, because the risks are quite concrete,” Dr. Lester said.

Having the command structure embrace the program went a long way toward broadening adoption. “It was really important to get commanders to support the program and even to share that they have participated with their own children,” she said.

In the program, initial screening is followed by informational sessions with the UCLA-trained providers on the impact of military-related stressors on children, parents, and families.

In subsequent sessions, families start building a graphic family narrative timeline, with children over 6 and parents contributing their individual interpretations of past events – moves, deployments, life changes. On the military installations, the timelines are drawn on paper; many families in civilian settings, meanwhile, have worked remotely from their homes with providers at UCLA to create timelines on the computer.

“Then we do individual and family-level cognitive-behavioral skill building, such as emotional regulation, goal setting and problem solving,” Dr. Lester said. “We also help parents and children recognize and manage deployment reminders – including trauma and loss reminders,” she said. Family members work together to articulate their collective goals.

Benefits are sustained

Dr. Lester’s study looked at 3,499 parents and 3,810 children (average age, 7) who participated. Families averaged 4.5 deployments before taking part in the program.

At exit, percentages of clinically meaningful anxiety and depression symptoms decreased from approximately 23% of all parents at intake to about 11%, and remained similarly low at 1 month and 6 months after program completion (range of adjusted odds ratios: 0.29-0.36).

Both civilian and service member parents reported clinically meaningful and statistically significant decreases in PTSD symptoms, which was notable because the intervention was not designed as a clinical treatment program but rather a psychoeducation program.

Children older than 8 years saw significant improvements in self-reported anxiety symptoms, with prevalence from 14.5% at intake to 11.8% at follow up.

Transitioning with families

After its initial adaptation from civilian interventions, then its broad application and scaling up over a decade in military settings, FOCUS must now transition to communities where military and veteran families live.

Between 3 and 4 million military-connected children live in the United States, with about 2 million in families that have transitioned out of active-duty military. “In the population that we serve, the average 10-year-old kid has been through at least four deployments, two of them combat related,” with many individual and community level exposures to trauma and loss, Dr. Lester explained.

A parent’s leaving active duty does not necessarily change risk for families, she said in an interview. “Our observation is that there’s a lot of reactivity and reminders in these families that persist – when somebody comes back highly activated, when there are threats of separation, and fear and danger, and if you do have underlying PTSD risk, that reactivity can be reactivated even after transition to civilian life.”

Teams at UCLA work to train providers in the FOCUS interventions and certify them in the different models for couples or families with children. The UCLA team will travel to conduct training, or practitioners can train at UCLA.

“We’re taking these components that have been most effective and continuing to refine them and integrate them into systems so that they reach people where they’re living,” Dr. Lester said, adding that she would encourage any clinician working with military families to get in touch via the program’s website.

She said some of the lessons learned from adapting to a military setting apply in civilian contexts as well – including the emphasis of the program as training, rather than diagnosis and treatment.

“I don’t think it reduces the impact or relevance of the intervention to have [FOCUS] inside a traditional mental health setting,” she said. “But in settings where it is essential to reach out and engage people who might not be coming into the clinic, it is important to highlight that this is an educational preventive program.”

Dr. Lester’s group is now conducting a research study of one FOCUS early childhood intervention in community settings.

Like military families, civilian families also embrace the concept of preparedness, she said. “They want to feel they have the skills to navigate whatever challenges come their way.”

SAN ANTONIO– As foreign wars wind down, and more families of military members and veterans receive care in civilian settings, an intervention used successfully on military bases to help families reduce risk of serious psychological disorders is being extended to civilian practices.

In the past decade, some 650,000 military and veteran family members have gone through Families Overcoming Under Stress, or FOCUS, a group of family-based interventions developed by a team led by psychiatrist Dr. Patricia E. Lester, director of the Nathanson Family Resilience Center at UCLA Health in Los Angeles.

Courtesy Anne Allhoff

Dr. Lester and her UCLA colleagues first adapted FOCUS at Marine Corps Base Camp Pendleton, San Diego, in 2006. Two years later, they implemented the program for the U.S. Navy Bureau of Medicine and Surgery at 22 Navy, Marine, Army, and Air Force installations in the United States and overseas. Now, with as many as 70% of active-duty military members living in civilian communities and about half of military-affiliated children getting health care in the civilian system, the program is being adapted to follow veterans’ families as they transition home.

The UCLA FOCUS team also is training community providers and extending technology platforms “to deliver our programs, monitor them, and put them in the hands of people where they live,” Dr. Lester said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

New research from a longitudinal observational study assessing more than 2,600 families with children who participated in the program in the United States and Japan on military bases, published recently online, shows that the intervention has been well received, with about 70% of families completing it. In addition, its positive impact on psychological health outcomes for parents and children was sustained (J Am Acad Child Adolesc Psychiatry. 2015 [doi: http://dx.doi.org/10.1016/j.jaac.2015.10.009]).

“Consistently what we’ve found is that doing a preventive educational program early on is an opportunity to engage families before they may need mental health treatment – reducing anxiety, depression, and [posttraumatic stress disorder] in adults, strengthening family functioning, and improving internalizing and externalizing symptoms in kids,” Dr. Lester said.

The latest research is based on a secondary analysis of FOCUS data collected between 2008 and 2013. Significant improvements for parental anxiety, posttraumatic stress, and depression symptoms occurred in service member and civilian parents, and child anxiety symptoms improved in boys and girls. Importantly, those reductions were maintained 6 months after the intervention ended.

Roots of intervention

The model for FOCUS derives from two civilian interventions developed over the past 15 years, one of them for families in which a parent is depressed, and another for those in which a parent is medically ill. FOCUS also incorporated elements of a third intervention used with families living in postwar Bosnia-Herzegovina and in New York City after the terrorist attacks of Sept.11, 2001.

“We know from decades of developmental literature that if a parent is not doing well in terms of depression, anxiety, or PTSD, it represents an ongoing risk for children,” Dr. Lester said. In military and veteran populations, “family approaches are critical.”

About a third of combat service members and veterans are estimated to have depression, PTSD, or a traumatic brain injury – and an emerging body of research is showing that their children are at elevated risk for social, academic, and emotional problems.

The FOCUS program, which generally lasts 8 sessions over 6-8 weeks, starts with real-time web-based screening of psychological health measures, using a set of standardized behavioral health, family adjustment, and coping assessments to assess risk and customize the intervention. “We sit down with the family; we identify their strengths and where they may be having difficulties,” Dr. Lester said.

About a quarter of the parents in Dr. Lester’s study had clinically meaningful anxiety or depression symptoms at intake, with civilian spouses reporting slightly more than military members. Also, some 31% of civilian spouses had PTSD symptoms at baseline, compared with 26% of military members – an unexpected finding, Dr. Lester said. Among children, 35% of boys and 25% of girls had social difficulties at baseline.

Location of intervention is key

Rolling FOCUS out on military installations required attention to military family culture. A voluntary program, it was implemented to service members as a form of training, rather than counseling or a mental health intervention, though part of its objective was to help to bridge gaps to mental health treatment for those who needed it.

Importantly, the intervention was delivered in community centers or retail spaces in lieu of mental health facilities on bases. “Military families may be reluctant to come for behavioral health services because of stigma or concern about their job – the same barriers we see in civilian communities but amplified, because the risks are quite concrete,” Dr. Lester said.

Having the command structure embrace the program went a long way toward broadening adoption. “It was really important to get commanders to support the program and even to share that they have participated with their own children,” she said.

In the program, initial screening is followed by informational sessions with the UCLA-trained providers on the impact of military-related stressors on children, parents, and families.

In subsequent sessions, families start building a graphic family narrative timeline, with children over 6 and parents contributing their individual interpretations of past events – moves, deployments, life changes. On the military installations, the timelines are drawn on paper; many families in civilian settings, meanwhile, have worked remotely from their homes with providers at UCLA to create timelines on the computer.

“Then we do individual and family-level cognitive-behavioral skill building, such as emotional regulation, goal setting and problem solving,” Dr. Lester said. “We also help parents and children recognize and manage deployment reminders – including trauma and loss reminders,” she said. Family members work together to articulate their collective goals.

Benefits are sustained

Dr. Lester’s study looked at 3,499 parents and 3,810 children (average age, 7) who participated. Families averaged 4.5 deployments before taking part in the program.

At exit, percentages of clinically meaningful anxiety and depression symptoms decreased from approximately 23% of all parents at intake to about 11%, and remained similarly low at 1 month and 6 months after program completion (range of adjusted odds ratios: 0.29-0.36).

Both civilian and service member parents reported clinically meaningful and statistically significant decreases in PTSD symptoms, which was notable because the intervention was not designed as a clinical treatment program but rather a psychoeducation program.

Children older than 8 years saw significant improvements in self-reported anxiety symptoms, with prevalence from 14.5% at intake to 11.8% at follow up.

Transitioning with families

After its initial adaptation from civilian interventions, then its broad application and scaling up over a decade in military settings, FOCUS must now transition to communities where military and veteran families live.

Between 3 and 4 million military-connected children live in the United States, with about 2 million in families that have transitioned out of active-duty military. “In the population that we serve, the average 10-year-old kid has been through at least four deployments, two of them combat related,” with many individual and community level exposures to trauma and loss, Dr. Lester explained.

A parent’s leaving active duty does not necessarily change risk for families, she said in an interview. “Our observation is that there’s a lot of reactivity and reminders in these families that persist – when somebody comes back highly activated, when there are threats of separation, and fear and danger, and if you do have underlying PTSD risk, that reactivity can be reactivated even after transition to civilian life.”

Teams at UCLA work to train providers in the FOCUS interventions and certify them in the different models for couples or families with children. The UCLA team will travel to conduct training, or practitioners can train at UCLA.

“We’re taking these components that have been most effective and continuing to refine them and integrate them into systems so that they reach people where they’re living,” Dr. Lester said, adding that she would encourage any clinician working with military families to get in touch via the program’s website.

She said some of the lessons learned from adapting to a military setting apply in civilian contexts as well – including the emphasis of the program as training, rather than diagnosis and treatment.

“I don’t think it reduces the impact or relevance of the intervention to have [FOCUS] inside a traditional mental health setting,” she said. “But in settings where it is essential to reach out and engage people who might not be coming into the clinic, it is important to highlight that this is an educational preventive program.”

Dr. Lester’s group is now conducting a research study of one FOCUS early childhood intervention in community settings.

Like military families, civilian families also embrace the concept of preparedness, she said. “They want to feel they have the skills to navigate whatever challenges come their way.”

SAN ANTONIO– As foreign wars wind down, and more families of military members and veterans receive care in civilian settings, an intervention used successfully on military bases to help families reduce risk of serious psychological disorders is being extended to civilian practices.

In the past decade, some 650,000 military and veteran family members have gone through Families Overcoming Under Stress, or FOCUS, a group of family-based interventions developed by a team led by psychiatrist Dr. Patricia E. Lester, director of the Nathanson Family Resilience Center at UCLA Health in Los Angeles.

Courtesy Anne Allhoff

Dr. Lester and her UCLA colleagues first adapted FOCUS at Marine Corps Base Camp Pendleton, San Diego, in 2006. Two years later, they implemented the program for the U.S. Navy Bureau of Medicine and Surgery at 22 Navy, Marine, Army, and Air Force installations in the United States and overseas. Now, with as many as 70% of active-duty military members living in civilian communities and about half of military-affiliated children getting health care in the civilian system, the program is being adapted to follow veterans’ families as they transition home.

The UCLA FOCUS team also is training community providers and extending technology platforms “to deliver our programs, monitor them, and put them in the hands of people where they live,” Dr. Lester said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

New research from a longitudinal observational study assessing more than 2,600 families with children who participated in the program in the United States and Japan on military bases, published recently online, shows that the intervention has been well received, with about 70% of families completing it. In addition, its positive impact on psychological health outcomes for parents and children was sustained (J Am Acad Child Adolesc Psychiatry. 2015 [doi: http://dx.doi.org/10.1016/j.jaac.2015.10.009]).

“Consistently what we’ve found is that doing a preventive educational program early on is an opportunity to engage families before they may need mental health treatment – reducing anxiety, depression, and [posttraumatic stress disorder] in adults, strengthening family functioning, and improving internalizing and externalizing symptoms in kids,” Dr. Lester said.

The latest research is based on a secondary analysis of FOCUS data collected between 2008 and 2013. Significant improvements for parental anxiety, posttraumatic stress, and depression symptoms occurred in service member and civilian parents, and child anxiety symptoms improved in boys and girls. Importantly, those reductions were maintained 6 months after the intervention ended.

Roots of intervention

The model for FOCUS derives from two civilian interventions developed over the past 15 years, one of them for families in which a parent is depressed, and another for those in which a parent is medically ill. FOCUS also incorporated elements of a third intervention used with families living in postwar Bosnia-Herzegovina and in New York City after the terrorist attacks of Sept.11, 2001.

“We know from decades of developmental literature that if a parent is not doing well in terms of depression, anxiety, or PTSD, it represents an ongoing risk for children,” Dr. Lester said. In military and veteran populations, “family approaches are critical.”

About a third of combat service members and veterans are estimated to have depression, PTSD, or a traumatic brain injury – and an emerging body of research is showing that their children are at elevated risk for social, academic, and emotional problems.

The FOCUS program, which generally lasts 8 sessions over 6-8 weeks, starts with real-time web-based screening of psychological health measures, using a set of standardized behavioral health, family adjustment, and coping assessments to assess risk and customize the intervention. “We sit down with the family; we identify their strengths and where they may be having difficulties,” Dr. Lester said.

About a quarter of the parents in Dr. Lester’s study had clinically meaningful anxiety or depression symptoms at intake, with civilian spouses reporting slightly more than military members. Also, some 31% of civilian spouses had PTSD symptoms at baseline, compared with 26% of military members – an unexpected finding, Dr. Lester said. Among children, 35% of boys and 25% of girls had social difficulties at baseline.

Location of intervention is key

Rolling FOCUS out on military installations required attention to military family culture. A voluntary program, it was implemented to service members as a form of training, rather than counseling or a mental health intervention, though part of its objective was to help to bridge gaps to mental health treatment for those who needed it.

Importantly, the intervention was delivered in community centers or retail spaces in lieu of mental health facilities on bases. “Military families may be reluctant to come for behavioral health services because of stigma or concern about their job – the same barriers we see in civilian communities but amplified, because the risks are quite concrete,” Dr. Lester said.

Having the command structure embrace the program went a long way toward broadening adoption. “It was really important to get commanders to support the program and even to share that they have participated with their own children,” she said.

In the program, initial screening is followed by informational sessions with the UCLA-trained providers on the impact of military-related stressors on children, parents, and families.

In subsequent sessions, families start building a graphic family narrative timeline, with children over 6 and parents contributing their individual interpretations of past events – moves, deployments, life changes. On the military installations, the timelines are drawn on paper; many families in civilian settings, meanwhile, have worked remotely from their homes with providers at UCLA to create timelines on the computer.

“Then we do individual and family-level cognitive-behavioral skill building, such as emotional regulation, goal setting and problem solving,” Dr. Lester said. “We also help parents and children recognize and manage deployment reminders – including trauma and loss reminders,” she said. Family members work together to articulate their collective goals.

Benefits are sustained

Dr. Lester’s study looked at 3,499 parents and 3,810 children (average age, 7) who participated. Families averaged 4.5 deployments before taking part in the program.

At exit, percentages of clinically meaningful anxiety and depression symptoms decreased from approximately 23% of all parents at intake to about 11%, and remained similarly low at 1 month and 6 months after program completion (range of adjusted odds ratios: 0.29-0.36).

Both civilian and service member parents reported clinically meaningful and statistically significant decreases in PTSD symptoms, which was notable because the intervention was not designed as a clinical treatment program but rather a psychoeducation program.

Children older than 8 years saw significant improvements in self-reported anxiety symptoms, with prevalence from 14.5% at intake to 11.8% at follow up.

Transitioning with families

After its initial adaptation from civilian interventions, then its broad application and scaling up over a decade in military settings, FOCUS must now transition to communities where military and veteran families live.

Between 3 and 4 million military-connected children live in the United States, with about 2 million in families that have transitioned out of active-duty military. “In the population that we serve, the average 10-year-old kid has been through at least four deployments, two of them combat related,” with many individual and community level exposures to trauma and loss, Dr. Lester explained.

A parent’s leaving active duty does not necessarily change risk for families, she said in an interview. “Our observation is that there’s a lot of reactivity and reminders in these families that persist – when somebody comes back highly activated, when there are threats of separation, and fear and danger, and if you do have underlying PTSD risk, that reactivity can be reactivated even after transition to civilian life.”

Teams at UCLA work to train providers in the FOCUS interventions and certify them in the different models for couples or families with children. The UCLA team will travel to conduct training, or practitioners can train at UCLA.

“We’re taking these components that have been most effective and continuing to refine them and integrate them into systems so that they reach people where they’re living,” Dr. Lester said, adding that she would encourage any clinician working with military families to get in touch via the program’s website.

She said some of the lessons learned from adapting to a military setting apply in civilian contexts as well – including the emphasis of the program as training, rather than diagnosis and treatment.

“I don’t think it reduces the impact or relevance of the intervention to have [FOCUS] inside a traditional mental health setting,” she said. “But in settings where it is essential to reach out and engage people who might not be coming into the clinic, it is important to highlight that this is an educational preventive program.”

Dr. Lester’s group is now conducting a research study of one FOCUS early childhood intervention in community settings.

Like military families, civilian families also embrace the concept of preparedness, she said. “They want to feel they have the skills to navigate whatever challenges come their way.”

SAN ANTONIO– Results from a pilot randomized double-blind trial suggest that repetitive transcranial stimulation, or rTMS, a technology currently approved to treat depression that is being investigated in a range of psychiatric disorders, might be a viable treatment strategy to improve executive function in young people with autism spectrum disorder (ASD).

The findings were presented by Dr. Stephanie Ameis of the Campbell Family Mental Health Research Institute in Toronto at the annual meeting American Academy of Child and Adolescent Psychiatry.

Impairments in executive function are common among higher functioning people with ASD. Previous studies have found executive function impairments to have common neurobiologic underpinnings. No studies to date have investigated rTMS on executive function in autism, but previous research by Dr. Ameis’s colleague and coauthor on the study, Dr. Z. Jeff Daskalakis, found that a course of rTMS significantly improved executive function among people with schizophrenia (Biol Psychiatry. 2013;73[6]:510-7).

Dr. Ameis and her colleagues hypothesized that a similar treatment approach might be feasible in people with ASD with known executive function impairment.

The researchers randomized 18 patients aged 16-35 years to 4 weeks of rTMS (20Hz) to the dorsolateral prefrontal cortex or sham treatment. All subjects were clinically stable, with an IQ greater than 70 (mean 95) and a qualifying measure of disability on the BRIEF (Behavior Rating Inventory of Executive Functions) assessment tool used to measure real-world impairment.

MRI and cognitive assessment were performed at baseline and 1 month after the treatment period ended. Baseline analysis of diffusion MRI indicated a trend toward a significant positive association between working memory scores on the BRIEF and white matter structures along the anterior thalamic radiation. Though white matter integrity in this part of the brain has been linked to executive function in other disorders, Dr. Ameis cautioned that the MRI findings in her study were preliminary and that it was too early to draw conclusions from them.

Mean age in the study was 23 years. Dr. Ameis said she hopes to continue to recruit a younger cohort, but that recruitment challenges led the group to expand an initial targeted age range of 16-25 years up to 35 years.

“We want to focus our intervention on the transition period to adulthood, as this is a time where effective interventions can really make an impact on individuals’ successful transition to work and school as young adults.”

The goal, Dr. Ameis said, “is to see if rTMS is feasible for this particular indication or treatment target, and so it’s the first study that’s really used a rigorous sham study design for this indication. We’re seeing whether people are interested and able to tolerate the 4-week protocol, as well as the other aspects of our study and secondarily, whether we are changing things with regard to [executive function].”

The protocol was well tolerated, the researchers found, with the time commitment – about 30 minutes a day, 5 days a week – being the biggest demand on subjects. rTMS was associated with no adverse effects except headaches around treatment times.

The pilot study established tolerability and feasibility in this patient group, Dr. Ameis said. Now the investigators will measure differences in executive function after a second year of recruitment to double the current sample size.

Dr. Ameis reported no conflicts of interest related to the findings. A coauthor on the study, Dr. Paul E. Croarkin, reported funding from Pfizer, and study supplies and genotyping from Assurex. Dr. Daskalakis acknowledged funding from Neuronetics.

SAN ANTONIO– Results from a pilot randomized double-blind trial suggest that repetitive transcranial stimulation, or rTMS, a technology currently approved to treat depression that is being investigated in a range of psychiatric disorders, might be a viable treatment strategy to improve executive function in young people with autism spectrum disorder (ASD).

The findings were presented by Dr. Stephanie Ameis of the Campbell Family Mental Health Research Institute in Toronto at the annual meeting American Academy of Child and Adolescent Psychiatry.

Impairments in executive function are common among higher functioning people with ASD. Previous studies have found executive function impairments to have common neurobiologic underpinnings. No studies to date have investigated rTMS on executive function in autism, but previous research by Dr. Ameis’s colleague and coauthor on the study, Dr. Z. Jeff Daskalakis, found that a course of rTMS significantly improved executive function among people with schizophrenia (Biol Psychiatry. 2013;73[6]:510-7).

Dr. Ameis and her colleagues hypothesized that a similar treatment approach might be feasible in people with ASD with known executive function impairment.

The researchers randomized 18 patients aged 16-35 years to 4 weeks of rTMS (20Hz) to the dorsolateral prefrontal cortex or sham treatment. All subjects were clinically stable, with an IQ greater than 70 (mean 95) and a qualifying measure of disability on the BRIEF (Behavior Rating Inventory of Executive Functions) assessment tool used to measure real-world impairment.

MRI and cognitive assessment were performed at baseline and 1 month after the treatment period ended. Baseline analysis of diffusion MRI indicated a trend toward a significant positive association between working memory scores on the BRIEF and white matter structures along the anterior thalamic radiation. Though white matter integrity in this part of the brain has been linked to executive function in other disorders, Dr. Ameis cautioned that the MRI findings in her study were preliminary and that it was too early to draw conclusions from them.

Mean age in the study was 23 years. Dr. Ameis said she hopes to continue to recruit a younger cohort, but that recruitment challenges led the group to expand an initial targeted age range of 16-25 years up to 35 years.

“We want to focus our intervention on the transition period to adulthood, as this is a time where effective interventions can really make an impact on individuals’ successful transition to work and school as young adults.”

The goal, Dr. Ameis said, “is to see if rTMS is feasible for this particular indication or treatment target, and so it’s the first study that’s really used a rigorous sham study design for this indication. We’re seeing whether people are interested and able to tolerate the 4-week protocol, as well as the other aspects of our study and secondarily, whether we are changing things with regard to [executive function].”

The protocol was well tolerated, the researchers found, with the time commitment – about 30 minutes a day, 5 days a week – being the biggest demand on subjects. rTMS was associated with no adverse effects except headaches around treatment times.

The pilot study established tolerability and feasibility in this patient group, Dr. Ameis said. Now the investigators will measure differences in executive function after a second year of recruitment to double the current sample size.

Dr. Ameis reported no conflicts of interest related to the findings. A coauthor on the study, Dr. Paul E. Croarkin, reported funding from Pfizer, and study supplies and genotyping from Assurex. Dr. Daskalakis acknowledged funding from Neuronetics.

SAN ANTONIO– Results from a pilot randomized double-blind trial suggest that repetitive transcranial stimulation, or rTMS, a technology currently approved to treat depression that is being investigated in a range of psychiatric disorders, might be a viable treatment strategy to improve executive function in young people with autism spectrum disorder (ASD).

The findings were presented by Dr. Stephanie Ameis of the Campbell Family Mental Health Research Institute in Toronto at the annual meeting American Academy of Child and Adolescent Psychiatry.

Impairments in executive function are common among higher functioning people with ASD. Previous studies have found executive function impairments to have common neurobiologic underpinnings. No studies to date have investigated rTMS on executive function in autism, but previous research by Dr. Ameis’s colleague and coauthor on the study, Dr. Z. Jeff Daskalakis, found that a course of rTMS significantly improved executive function among people with schizophrenia (Biol Psychiatry. 2013;73[6]:510-7).

Dr. Ameis and her colleagues hypothesized that a similar treatment approach might be feasible in people with ASD with known executive function impairment.

The researchers randomized 18 patients aged 16-35 years to 4 weeks of rTMS (20Hz) to the dorsolateral prefrontal cortex or sham treatment. All subjects were clinically stable, with an IQ greater than 70 (mean 95) and a qualifying measure of disability on the BRIEF (Behavior Rating Inventory of Executive Functions) assessment tool used to measure real-world impairment.

MRI and cognitive assessment were performed at baseline and 1 month after the treatment period ended. Baseline analysis of diffusion MRI indicated a trend toward a significant positive association between working memory scores on the BRIEF and white matter structures along the anterior thalamic radiation. Though white matter integrity in this part of the brain has been linked to executive function in other disorders, Dr. Ameis cautioned that the MRI findings in her study were preliminary and that it was too early to draw conclusions from them.

Mean age in the study was 23 years. Dr. Ameis said she hopes to continue to recruit a younger cohort, but that recruitment challenges led the group to expand an initial targeted age range of 16-25 years up to 35 years.

“We want to focus our intervention on the transition period to adulthood, as this is a time where effective interventions can really make an impact on individuals’ successful transition to work and school as young adults.”

The goal, Dr. Ameis said, “is to see if rTMS is feasible for this particular indication or treatment target, and so it’s the first study that’s really used a rigorous sham study design for this indication. We’re seeing whether people are interested and able to tolerate the 4-week protocol, as well as the other aspects of our study and secondarily, whether we are changing things with regard to [executive function].”

The protocol was well tolerated, the researchers found, with the time commitment – about 30 minutes a day, 5 days a week – being the biggest demand on subjects. rTMS was associated with no adverse effects except headaches around treatment times.

The pilot study established tolerability and feasibility in this patient group, Dr. Ameis said. Now the investigators will measure differences in executive function after a second year of recruitment to double the current sample size.

Dr. Ameis reported no conflicts of interest related to the findings. A coauthor on the study, Dr. Paul E. Croarkin, reported funding from Pfizer, and study supplies and genotyping from Assurex. Dr. Daskalakis acknowledged funding from Neuronetics.

SAN ANTONIO– Results from a pilot randomized double-blind trial suggest that repetitive transcranial stimulation, or rTMS, a technology currently approved to treat depression that is being investigated in a range of psychiatric disorders, might be a viable treatment strategy to improve executive function in young people with autism spectrum disorder (ASD).

The findings were presented by Dr. Stephanie Ameis of the Campbell Family Mental Health Research Institute in Toronto at the annual meeting American Academy of Child and Adolescent Psychiatry.

Impairments in executive function are common among higher functioning people with ASD. Previous studies have found executive function impairments to have common neurobiologic underpinnings. No studies to date have investigated rTMS on executive function in autism, but previous research by Dr. Ameis’s colleague and coauthor on the study, Dr. Z. Jeff Daskalakis, found that a course of rTMS significantly improved executive function among people with schizophrenia (Biol Psychiatry. 2013;73[6]:510-7).

Dr. Ameis and her colleagues hypothesized that a similar treatment approach might be feasible in people with ASD with known executive function impairment.

The researchers randomized 18 patients aged 16-35 years to 4 weeks of rTMS (20Hz) to the dorsolateral prefrontal cortex or sham treatment. All subjects were clinically stable, with an IQ greater than 70 (mean 95) and a qualifying measure of disability on the BRIEF (Behavior Rating Inventory of Executive Functions) assessment tool used to measure real-world impairment.

MRI and cognitive assessment were performed at baseline and 1 month after the treatment period ended. Baseline analysis of diffusion MRI indicated a trend toward a significant positive association between working memory scores on the BRIEF and white matter structures along the anterior thalamic radiation. Though white matter integrity in this part of the brain has been linked to executive function in other disorders, Dr. Ameis cautioned that the MRI findings in her study were preliminary and that it was too early to draw conclusions from them.

Mean age in the study was 23 years. Dr. Ameis said she hopes to continue to recruit a younger cohort, but that recruitment challenges led the group to expand an initial targeted age range of 16-25 years up to 35 years.

“We want to focus our intervention on the transition period to adulthood, as this is a time where effective interventions can really make an impact on individuals’ successful transition to work and school as young adults.”

The goal, Dr. Ameis said, “is to see if rTMS is feasible for this particular indication or treatment target, and so it’s the first study that’s really used a rigorous sham study design for this indication. We’re seeing whether people are interested and able to tolerate the 4-week protocol, as well as the other aspects of our study and secondarily, whether we are changing things with regard to [executive function].”

The protocol was well tolerated, the researchers found, with the time commitment – about 30 minutes a day, 5 days a week – being the biggest demand on subjects. rTMS was associated with no adverse effects except headaches around treatment times.

The pilot study established tolerability and feasibility in this patient group, Dr. Ameis said. Now the investigators will measure differences in executive function after a second year of recruitment to double the current sample size.

Dr. Ameis reported no conflicts of interest related to the findings. A coauthor on the study, Dr. Paul E. Croarkin, reported funding from Pfizer, and study supplies and genotyping from Assurex. Dr. Daskalakis acknowledged funding from Neuronetics.

SAN ANTONIO– Results from a pilot randomized double-blind trial suggest that repetitive transcranial stimulation, or rTMS, a technology currently approved to treat depression that is being investigated in a range of psychiatric disorders, might be a viable treatment strategy to improve executive function in young people with autism spectrum disorder (ASD).

The findings were presented by Dr. Stephanie Ameis of the Campbell Family Mental Health Research Institute in Toronto at the annual meeting American Academy of Child and Adolescent Psychiatry.

Impairments in executive function are common among higher functioning people with ASD. Previous studies have found executive function impairments to have common neurobiologic underpinnings. No studies to date have investigated rTMS on executive function in autism, but previous research by Dr. Ameis’s colleague and coauthor on the study, Dr. Z. Jeff Daskalakis, found that a course of rTMS significantly improved executive function among people with schizophrenia (Biol Psychiatry. 2013;73[6]:510-7).

Dr. Ameis and her colleagues hypothesized that a similar treatment approach might be feasible in people with ASD with known executive function impairment.

The researchers randomized 18 patients aged 16-35 years to 4 weeks of rTMS (20Hz) to the dorsolateral prefrontal cortex or sham treatment. All subjects were clinically stable, with an IQ greater than 70 (mean 95) and a qualifying measure of disability on the BRIEF (Behavior Rating Inventory of Executive Functions) assessment tool used to measure real-world impairment.

MRI and cognitive assessment were performed at baseline and 1 month after the treatment period ended. Baseline analysis of diffusion MRI indicated a trend toward a significant positive association between working memory scores on the BRIEF and white matter structures along the anterior thalamic radiation. Though white matter integrity in this part of the brain has been linked to executive function in other disorders, Dr. Ameis cautioned that the MRI findings in her study were preliminary and that it was too early to draw conclusions from them.

Mean age in the study was 23 years. Dr. Ameis said she hopes to continue to recruit a younger cohort, but that recruitment challenges led the group to expand an initial targeted age range of 16-25 years up to 35 years.

“We want to focus our intervention on the transition period to adulthood, as this is a time where effective interventions can really make an impact on individuals’ successful transition to work and school as young adults.”

The goal, Dr. Ameis said, “is to see if rTMS is feasible for this particular indication or treatment target, and so it’s the first study that’s really used a rigorous sham study design for this indication. We’re seeing whether people are interested and able to tolerate the 4-week protocol, as well as the other aspects of our study and secondarily, whether we are changing things with regard to [executive function].”

The protocol was well tolerated, the researchers found, with the time commitment – about 30 minutes a day, 5 days a week – being the biggest demand on subjects. rTMS was associated with no adverse effects except headaches around treatment times.

The pilot study established tolerability and feasibility in this patient group, Dr. Ameis said. Now the investigators will measure differences in executive function after a second year of recruitment to double the current sample size.

Dr. Ameis reported no conflicts of interest related to the findings. A coauthor on the study, Dr. Paul E. Croarkin, reported funding from Pfizer, and study supplies and genotyping from Assurex. Dr. Daskalakis acknowledged funding from Neuronetics.

SAN ANTONIO– Results from a pilot randomized double-blind trial suggest that repetitive transcranial stimulation, or rTMS, a technology currently approved to treat depression that is being investigated in a range of psychiatric disorders, might be a viable treatment strategy to improve executive function in young people with autism spectrum disorder (ASD).

The findings were presented by Dr. Stephanie Ameis of the Campbell Family Mental Health Research Institute in Toronto at the annual meeting American Academy of Child and Adolescent Psychiatry.

Impairments in executive function are common among higher functioning people with ASD. Previous studies have found executive function impairments to have common neurobiologic underpinnings. No studies to date have investigated rTMS on executive function in autism, but previous research by Dr. Ameis’s colleague and coauthor on the study, Dr. Z. Jeff Daskalakis, found that a course of rTMS significantly improved executive function among people with schizophrenia (Biol Psychiatry. 2013;73[6]:510-7).

Dr. Ameis and her colleagues hypothesized that a similar treatment approach might be feasible in people with ASD with known executive function impairment.

The researchers randomized 18 patients aged 16-35 years to 4 weeks of rTMS (20Hz) to the dorsolateral prefrontal cortex or sham treatment. All subjects were clinically stable, with an IQ greater than 70 (mean 95) and a qualifying measure of disability on the BRIEF (Behavior Rating Inventory of Executive Functions) assessment tool used to measure real-world impairment.

MRI and cognitive assessment were performed at baseline and 1 month after the treatment period ended. Baseline analysis of diffusion MRI indicated a trend toward a significant positive association between working memory scores on the BRIEF and white matter structures along the anterior thalamic radiation. Though white matter integrity in this part of the brain has been linked to executive function in other disorders, Dr. Ameis cautioned that the MRI findings in her study were preliminary and that it was too early to draw conclusions from them.

Mean age in the study was 23 years. Dr. Ameis said she hopes to continue to recruit a younger cohort, but that recruitment challenges led the group to expand an initial targeted age range of 16-25 years up to 35 years.

“We want to focus our intervention on the transition period to adulthood, as this is a time where effective interventions can really make an impact on individuals’ successful transition to work and school as young adults.”

The goal, Dr. Ameis said, “is to see if rTMS is feasible for this particular indication or treatment target, and so it’s the first study that’s really used a rigorous sham study design for this indication. We’re seeing whether people are interested and able to tolerate the 4-week protocol, as well as the other aspects of our study and secondarily, whether we are changing things with regard to [executive function].”

The protocol was well tolerated, the researchers found, with the time commitment – about 30 minutes a day, 5 days a week – being the biggest demand on subjects. rTMS was associated with no adverse effects except headaches around treatment times.

The pilot study established tolerability and feasibility in this patient group, Dr. Ameis said. Now the investigators will measure differences in executive function after a second year of recruitment to double the current sample size.

Dr. Ameis reported no conflicts of interest related to the findings. A coauthor on the study, Dr. Paul E. Croarkin, reported funding from Pfizer, and study supplies and genotyping from Assurex. Dr. Daskalakis acknowledged funding from Neuronetics.

SAN ANTONIO – New models of autism research and treatment are increasingly looking to study specific genetic causes, including Phelan-McDermid syndrome.

Phelan-McDermid Syndrome, or PMS, is caused by deletion or mutation of the SHANK3 gene and is characterized by intellectual disability, delayed or absent speech, hypotonia, and autism spectrum disorder (ASD). Children with PMS also often have an uneven gait and other motor difficulties.

SHANK3 deletions and mutations are thought responsible for up to 2% of ASD cases; however, aberrant behavior, such as irritability, lethargy, stereotypy, hyperactivity, and inappropriate speech have not been thoroughly investigated in PMS.

Erin Li, a 4th-year medical student, presented findings at the annual meeting of the American Academy of Child and Adolescent Psychiatry from a study in children with PMS that sought to discern whether a caregiver checklist for aberrant behavior used in diagnosing ASD and intellectual disabilities could pinpoint differences in aberrant behaviors between PMS and idiopathic ASD.

The study looked at two cohorts of children, 24 with ASD caused by PMS (mean age, 7.2 years; 14 males) and 23 with idiopathic ASD (mean age, 6.4 years;15 males) using the Aberrant Behavior Checklist (ABC) developed by Michael G. Aman, Ph.D., and his colleagues. Children in both cohorts had intellectual disability, reported Ms. Li, of the Icahn School of Medicine at Mount Sinai, New York.

The ABC is a 58-item parent-reported checklist, and Ms. Li and her colleagues did not find significant differences in the severity of aberrant behavior between groups. The results suggest that, similar to idiopathic ASD, aberrant behavior in PMS can be measured using the ABC.

However, only genetic screening can detect PMS, Ms. Li noted in an interview. The best tool is the chromosomal microarray (CMA) test.

Ms. Li’s research was conducted at the Seaver Autism Center at Mount Sinai, a clinical research group headed by Dr. Alexander Kolevzon. The team also is investigating several treatments for children with PMS, including with insulinlike growth factor–1 (IGF-1), which was seen in a small pilot study (n = 9) to be associated with significant improvement in social impairment and restrictive behaviors (Mol Autism. 2014 Dec 12;5[1]:54).

A larger study with IGF-1 is currently underway, and the group is beginning to investigate treatment of PMS with oxytocin, after results from an animal study suggested that it could improve social deficits in mice with SHANK3 deletions.

Ms. Li and her coauthors disclosed no conflicts of interest related to their findings. The director of the Seaver Autism Center, Joseph Buxbaum, Ph.D., and Mount Sinai hold a shared patent for the use of IGF-1 in PMS.

SAN ANTONIO – New models of autism research and treatment are increasingly looking to study specific genetic causes, including Phelan-McDermid syndrome.

Phelan-McDermid Syndrome, or PMS, is caused by deletion or mutation of the SHANK3 gene and is characterized by intellectual disability, delayed or absent speech, hypotonia, and autism spectrum disorder (ASD). Children with PMS also often have an uneven gait and other motor difficulties.

SHANK3 deletions and mutations are thought responsible for up to 2% of ASD cases; however, aberrant behavior, such as irritability, lethargy, stereotypy, hyperactivity, and inappropriate speech have not been thoroughly investigated in PMS.

Erin Li, a 4th-year medical student, presented findings at the annual meeting of the American Academy of Child and Adolescent Psychiatry from a study in children with PMS that sought to discern whether a caregiver checklist for aberrant behavior used in diagnosing ASD and intellectual disabilities could pinpoint differences in aberrant behaviors between PMS and idiopathic ASD.

The study looked at two cohorts of children, 24 with ASD caused by PMS (mean age, 7.2 years; 14 males) and 23 with idiopathic ASD (mean age, 6.4 years;15 males) using the Aberrant Behavior Checklist (ABC) developed by Michael G. Aman, Ph.D., and his colleagues. Children in both cohorts had intellectual disability, reported Ms. Li, of the Icahn School of Medicine at Mount Sinai, New York.

The ABC is a 58-item parent-reported checklist, and Ms. Li and her colleagues did not find significant differences in the severity of aberrant behavior between groups. The results suggest that, similar to idiopathic ASD, aberrant behavior in PMS can be measured using the ABC.

However, only genetic screening can detect PMS, Ms. Li noted in an interview. The best tool is the chromosomal microarray (CMA) test.

Ms. Li’s research was conducted at the Seaver Autism Center at Mount Sinai, a clinical research group headed by Dr. Alexander Kolevzon. The team also is investigating several treatments for children with PMS, including with insulinlike growth factor–1 (IGF-1), which was seen in a small pilot study (n = 9) to be associated with significant improvement in social impairment and restrictive behaviors (Mol Autism. 2014 Dec 12;5[1]:54).

A larger study with IGF-1 is currently underway, and the group is beginning to investigate treatment of PMS with oxytocin, after results from an animal study suggested that it could improve social deficits in mice with SHANK3 deletions.

Ms. Li and her coauthors disclosed no conflicts of interest related to their findings. The director of the Seaver Autism Center, Joseph Buxbaum, Ph.D., and Mount Sinai hold a shared patent for the use of IGF-1 in PMS.

SAN ANTONIO – New models of autism research and treatment are increasingly looking to study specific genetic causes, including Phelan-McDermid syndrome.

Phelan-McDermid Syndrome, or PMS, is caused by deletion or mutation of the SHANK3 gene and is characterized by intellectual disability, delayed or absent speech, hypotonia, and autism spectrum disorder (ASD). Children with PMS also often have an uneven gait and other motor difficulties.

SHANK3 deletions and mutations are thought responsible for up to 2% of ASD cases; however, aberrant behavior, such as irritability, lethargy, stereotypy, hyperactivity, and inappropriate speech have not been thoroughly investigated in PMS.

Erin Li, a 4th-year medical student, presented findings at the annual meeting of the American Academy of Child and Adolescent Psychiatry from a study in children with PMS that sought to discern whether a caregiver checklist for aberrant behavior used in diagnosing ASD and intellectual disabilities could pinpoint differences in aberrant behaviors between PMS and idiopathic ASD.

The study looked at two cohorts of children, 24 with ASD caused by PMS (mean age, 7.2 years; 14 males) and 23 with idiopathic ASD (mean age, 6.4 years;15 males) using the Aberrant Behavior Checklist (ABC) developed by Michael G. Aman, Ph.D., and his colleagues. Children in both cohorts had intellectual disability, reported Ms. Li, of the Icahn School of Medicine at Mount Sinai, New York.

The ABC is a 58-item parent-reported checklist, and Ms. Li and her colleagues did not find significant differences in the severity of aberrant behavior between groups. The results suggest that, similar to idiopathic ASD, aberrant behavior in PMS can be measured using the ABC.

However, only genetic screening can detect PMS, Ms. Li noted in an interview. The best tool is the chromosomal microarray (CMA) test.

Ms. Li’s research was conducted at the Seaver Autism Center at Mount Sinai, a clinical research group headed by Dr. Alexander Kolevzon. The team also is investigating several treatments for children with PMS, including with insulinlike growth factor–1 (IGF-1), which was seen in a small pilot study (n = 9) to be associated with significant improvement in social impairment and restrictive behaviors (Mol Autism. 2014 Dec 12;5[1]:54).

A larger study with IGF-1 is currently underway, and the group is beginning to investigate treatment of PMS with oxytocin, after results from an animal study suggested that it could improve social deficits in mice with SHANK3 deletions.

Ms. Li and her coauthors disclosed no conflicts of interest related to their findings. The director of the Seaver Autism Center, Joseph Buxbaum, Ph.D., and Mount Sinai hold a shared patent for the use of IGF-1 in PMS.

SAN ANTONIO – Simultaneous prescription of psychotropic drugs likely to cause problematic interactions increased in children over a 10-year period, according to findings from a review of Medicaid data presented at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Another study presented at AACAP, also using Medicaid data, found that children in areas underserved by child psychiatrists are likelier to be prescribed atypical antipsychotic drugs for nonpsychotic conditions than in areas where more child psychiatrists practice.

The polypharmacy study, presented by Dr. Regina Bussing of the University of Florida in Gainesville, looked at Medicaid records from 29 states to identify 45-day overlaps in concurrently prescribed psychiatric medications in children. The researchers used three commercially available interaction checkers to identify combinations classed as contraindicated.

Dr. Bussing and her colleagues found that the prevalence of scripts of two or more medications in different drug classes rose from 1999 through 2007 and plateaued afterward, meaning that anywhere from 18.3% to 27.7% children were prescribed at least one psychotropic drug. About 1.5% of children treated with two or more drugs received two atypical antipsychotics, and 0.6% were prescribed two stimulant classes.

The researchers looked at prescription data for cohorts of between 485,874 and 966,613 patients for each 2-year bracket studied. Throughout the study period, the overall prevalence of psychotropic drug combinations rated as “contraindicated” or having “major” interaction risks was 0.21% for children 5 years and under, 1.12% for children 6-9 years, 2.06% for ages 10-14 years, and 2.83% for children 15-17.

In Florida, the prevalence of potentially risky prescriptions was considerably higher, at 0.46% of the youngest children and 3.92% of the oldest. The state of Florida “is No. 49 in funding for mental health; that might be one of the factors” promoting the polypharmacy trend, Dr. Bussing commented.

More common patterns classified as potentially risky that were seen in the study included combining a selective serotonin reuptake inhibitor with trazodone. This likely represents efforts by clinicians to target mood and insomnia symptoms simultaneously, suggested Dr. Bussing. However, adding trazodone can increase the risk of serotonin syndrome or cardiac conduction problems. As for other drug combinations seen in the study, “I don’t understand it at all. I’d love to know what people are trying to do,” she noted.

Dr. Bussing said further research was needed to better understand the clinical, rather than just theoretical, interaction risks of polypharmacy in this patient group. Electronic health records are increasingly programmed to alert to potential interactions, but clinicians routinely override them, she said, likely feeling the true risk to be lower than conveyed by interaction-checking databases.

Findings from a separate study showed that the use of atypical antipsychotic drugs varied widely by county in Maryland, and that children aged 4-17 years who lived in counties with more practicing child psychiatrists were less likely to be prescribed an atypical antipsychotic drug for a nonpsychotic condition, according to Dinci Pennap of the University of Maryland School of Pharmacy in Baltimore.

Ms. Pennap and colleagues reviewed Medicaid data for 133,247 children aged 4-17 years. Of these, 48,087 (36%) had one or more nonpsychotic diagnoses, and 9.6% of these received at least one prescription for an atypical antipsychotic drug between 2010 and 2012.

The investigators also determined from registries how many child psychiatrists practiced in the counties where subjects resided. Adequate coverage was calculated at one child psychiatrist per approximately 7,000 youth. Of the 24 counties in Maryland, 7 had no child psychiatrists, 10 had too few, and 7 had sufficient numbers.

Non-Hispanic black children in counties without any child psychiatrists were significantly more likely to receive an atypical antipsychotic drug, compared with other racial and ethnic groups (12.1% vs. 6.6%; P less than .0001). County variations accounted for 2.7% of atypical antipsychotic drug use in this population. The use of atypical antipsychotic drugs was also higher in children with multiple diagnoses.

“A major limitation here was that we couldn’t account for who was prescribing what because we are using county level data,” Ms. Pennap said. “However, the underlying statement is that someone besides child psychiatrists has to be doing [the prescribing]”; in some counties there were none practicing at all, Ms. Pennap said.

Moreover, “there is no indication in the Maryland Medicaid data that children on [atypical antipsychotic drugs] are being followed for metabolic or cardiovascular disorders” that might result from treatment, Ms. Pennap said.

Dr. Bussing’s study was funded by the University of Florida. She disclosed prior research support from Pfizer and Otsuka. Ms. Pennap’s study had no outside funding. She disclosed no conflicts of interest.

SAN ANTONIO – Simultaneous prescription of psychotropic drugs likely to cause problematic interactions increased in children over a 10-year period, according to findings from a review of Medicaid data presented at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Another study presented at AACAP, also using Medicaid data, found that children in areas underserved by child psychiatrists are likelier to be prescribed atypical antipsychotic drugs for nonpsychotic conditions than in areas where more child psychiatrists practice.

The polypharmacy study, presented by Dr. Regina Bussing of the University of Florida in Gainesville, looked at Medicaid records from 29 states to identify 45-day overlaps in concurrently prescribed psychiatric medications in children. The researchers used three commercially available interaction checkers to identify combinations classed as contraindicated.

Dr. Bussing and her colleagues found that the prevalence of scripts of two or more medications in different drug classes rose from 1999 through 2007 and plateaued afterward, meaning that anywhere from 18.3% to 27.7% children were prescribed at least one psychotropic drug. About 1.5% of children treated with two or more drugs received two atypical antipsychotics, and 0.6% were prescribed two stimulant classes.

The researchers looked at prescription data for cohorts of between 485,874 and 966,613 patients for each 2-year bracket studied. Throughout the study period, the overall prevalence of psychotropic drug combinations rated as “contraindicated” or having “major” interaction risks was 0.21% for children 5 years and under, 1.12% for children 6-9 years, 2.06% for ages 10-14 years, and 2.83% for children 15-17.

In Florida, the prevalence of potentially risky prescriptions was considerably higher, at 0.46% of the youngest children and 3.92% of the oldest. The state of Florida “is No. 49 in funding for mental health; that might be one of the factors” promoting the polypharmacy trend, Dr. Bussing commented.

More common patterns classified as potentially risky that were seen in the study included combining a selective serotonin reuptake inhibitor with trazodone. This likely represents efforts by clinicians to target mood and insomnia symptoms simultaneously, suggested Dr. Bussing. However, adding trazodone can increase the risk of serotonin syndrome or cardiac conduction problems. As for other drug combinations seen in the study, “I don’t understand it at all. I’d love to know what people are trying to do,” she noted.

Dr. Bussing said further research was needed to better understand the clinical, rather than just theoretical, interaction risks of polypharmacy in this patient group. Electronic health records are increasingly programmed to alert to potential interactions, but clinicians routinely override them, she said, likely feeling the true risk to be lower than conveyed by interaction-checking databases.

Findings from a separate study showed that the use of atypical antipsychotic drugs varied widely by county in Maryland, and that children aged 4-17 years who lived in counties with more practicing child psychiatrists were less likely to be prescribed an atypical antipsychotic drug for a nonpsychotic condition, according to Dinci Pennap of the University of Maryland School of Pharmacy in Baltimore.

Ms. Pennap and colleagues reviewed Medicaid data for 133,247 children aged 4-17 years. Of these, 48,087 (36%) had one or more nonpsychotic diagnoses, and 9.6% of these received at least one prescription for an atypical antipsychotic drug between 2010 and 2012.

The investigators also determined from registries how many child psychiatrists practiced in the counties where subjects resided. Adequate coverage was calculated at one child psychiatrist per approximately 7,000 youth. Of the 24 counties in Maryland, 7 had no child psychiatrists, 10 had too few, and 7 had sufficient numbers.

Non-Hispanic black children in counties without any child psychiatrists were significantly more likely to receive an atypical antipsychotic drug, compared with other racial and ethnic groups (12.1% vs. 6.6%; P less than .0001). County variations accounted for 2.7% of atypical antipsychotic drug use in this population. The use of atypical antipsychotic drugs was also higher in children with multiple diagnoses.

“A major limitation here was that we couldn’t account for who was prescribing what because we are using county level data,” Ms. Pennap said. “However, the underlying statement is that someone besides child psychiatrists has to be doing [the prescribing]”; in some counties there were none practicing at all, Ms. Pennap said.

Moreover, “there is no indication in the Maryland Medicaid data that children on [atypical antipsychotic drugs] are being followed for metabolic or cardiovascular disorders” that might result from treatment, Ms. Pennap said.

Dr. Bussing’s study was funded by the University of Florida. She disclosed prior research support from Pfizer and Otsuka. Ms. Pennap’s study had no outside funding. She disclosed no conflicts of interest.

SAN ANTONIO – Simultaneous prescription of psychotropic drugs likely to cause problematic interactions increased in children over a 10-year period, according to findings from a review of Medicaid data presented at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Another study presented at AACAP, also using Medicaid data, found that children in areas underserved by child psychiatrists are likelier to be prescribed atypical antipsychotic drugs for nonpsychotic conditions than in areas where more child psychiatrists practice.

The polypharmacy study, presented by Dr. Regina Bussing of the University of Florida in Gainesville, looked at Medicaid records from 29 states to identify 45-day overlaps in concurrently prescribed psychiatric medications in children. The researchers used three commercially available interaction checkers to identify combinations classed as contraindicated.

Dr. Bussing and her colleagues found that the prevalence of scripts of two or more medications in different drug classes rose from 1999 through 2007 and plateaued afterward, meaning that anywhere from 18.3% to 27.7% children were prescribed at least one psychotropic drug. About 1.5% of children treated with two or more drugs received two atypical antipsychotics, and 0.6% were prescribed two stimulant classes.

The researchers looked at prescription data for cohorts of between 485,874 and 966,613 patients for each 2-year bracket studied. Throughout the study period, the overall prevalence of psychotropic drug combinations rated as “contraindicated” or having “major” interaction risks was 0.21% for children 5 years and under, 1.12% for children 6-9 years, 2.06% for ages 10-14 years, and 2.83% for children 15-17.

In Florida, the prevalence of potentially risky prescriptions was considerably higher, at 0.46% of the youngest children and 3.92% of the oldest. The state of Florida “is No. 49 in funding for mental health; that might be one of the factors” promoting the polypharmacy trend, Dr. Bussing commented.

More common patterns classified as potentially risky that were seen in the study included combining a selective serotonin reuptake inhibitor with trazodone. This likely represents efforts by clinicians to target mood and insomnia symptoms simultaneously, suggested Dr. Bussing. However, adding trazodone can increase the risk of serotonin syndrome or cardiac conduction problems. As for other drug combinations seen in the study, “I don’t understand it at all. I’d love to know what people are trying to do,” she noted.

Dr. Bussing said further research was needed to better understand the clinical, rather than just theoretical, interaction risks of polypharmacy in this patient group. Electronic health records are increasingly programmed to alert to potential interactions, but clinicians routinely override them, she said, likely feeling the true risk to be lower than conveyed by interaction-checking databases.

Findings from a separate study showed that the use of atypical antipsychotic drugs varied widely by county in Maryland, and that children aged 4-17 years who lived in counties with more practicing child psychiatrists were less likely to be prescribed an atypical antipsychotic drug for a nonpsychotic condition, according to Dinci Pennap of the University of Maryland School of Pharmacy in Baltimore.

Ms. Pennap and colleagues reviewed Medicaid data for 133,247 children aged 4-17 years. Of these, 48,087 (36%) had one or more nonpsychotic diagnoses, and 9.6% of these received at least one prescription for an atypical antipsychotic drug between 2010 and 2012.

The investigators also determined from registries how many child psychiatrists practiced in the counties where subjects resided. Adequate coverage was calculated at one child psychiatrist per approximately 7,000 youth. Of the 24 counties in Maryland, 7 had no child psychiatrists, 10 had too few, and 7 had sufficient numbers.

Non-Hispanic black children in counties without any child psychiatrists were significantly more likely to receive an atypical antipsychotic drug, compared with other racial and ethnic groups (12.1% vs. 6.6%; P less than .0001). County variations accounted for 2.7% of atypical antipsychotic drug use in this population. The use of atypical antipsychotic drugs was also higher in children with multiple diagnoses.

“A major limitation here was that we couldn’t account for who was prescribing what because we are using county level data,” Ms. Pennap said. “However, the underlying statement is that someone besides child psychiatrists has to be doing [the prescribing]”; in some counties there were none practicing at all, Ms. Pennap said.

Moreover, “there is no indication in the Maryland Medicaid data that children on [atypical antipsychotic drugs] are being followed for metabolic or cardiovascular disorders” that might result from treatment, Ms. Pennap said.

Dr. Bussing’s study was funded by the University of Florida. She disclosed prior research support from Pfizer and Otsuka. Ms. Pennap’s study had no outside funding. She disclosed no conflicts of interest.

SAN ANTONIO – Teenagers with anorexia nervosa gained weight faster when taking the atypical antipsychotic drug olanzapine, according to results from an open-label study presented at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Olanzapine is used frequently off-label in the treatment of anorexia, said Dr. Wendy Spettigue of the Children’s Hospital of Eastern Ontario in Ottawa. In addition to the known metabolic effects of the drug, in clinical use “it seems to decrease eating disorder thoughts and preoccupations, and with that, resistance to taking the nutrition.” However, she noted, “there’s been little to date in terms of research in adolescents.”

One previous placebo-controlled pilot study in adolescent girls (n =20) found no differences in rate or amount of weight gain between olanzapine-treated and placebo groups (J Child Adolesc Psychopharmacol. 2011;21[3]:207-12).

Dr. Spettigue and colleagues’ study, the largest to date to look at olanzapine in this patient group, compared low-weight patients who received standard care plus olanzapine (n = 22) to those who received standard care only (n = 10), which included nutritional support and therapy. All but three patients were girls, 85% were inpatients, and median age at baseline was 15.5 years. The mean percentage of ideal body weight was 77% and 78%, respectively, for the two groups. Doses of olanzapine ranged from 2.5 mg to 7.5 mg, with most patients on 5 mg at bedtime.

Both groups showed significant weight gains across the 6-week study period. However, the intervention group saw a significantly greater rate of increase after week 3, with the olanzapine group gaining a mean 1.53 kg between weeks 3 and 4 (vs. 0.81 in the comparison group) and 2.64 kg between weeks 4 and 6 of treatment (vs. 1.51; P = .012).

Patients in the study “were told that whether they take the medication or not they need to get to their healthy weight. We taper them off once they have reached their healthy weight, and many of them end up on SSRIs alongside family therapy as part of ongoing treatment,” Dr. Spettigue said.

Secondary outcomes in the study included the Multidimensional Anxiety Scale for Children, the Eating Disorder Examination Questionnaire, and the Children’s Depression Inventory.  Both the intervention and comparison groups, which were well matched on these measures at baseline, saw decreases for anxiety (P = .27), depression (P less than .1), and eating disorders (P = .04). Between-group differences did not reach statistical significance. 

The researchers did note elevations in lipid profiles in about a third of the olanzapine-treated patients.  Dr. Spettigue said she did not find this worrisome in this patient group, who were only on the medication for a short time, but she stressed that medical monitoring was extremely important.

The W. Garfield Weston Foundation funded the study. The investigators reported no conflicts of interest.

SAN ANTONIO – Teenagers with anorexia nervosa gained weight faster when taking the atypical antipsychotic drug olanzapine, according to results from an open-label study presented at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Olanzapine is used frequently off-label in the treatment of anorexia, said Dr. Wendy Spettigue of the Children’s Hospital of Eastern Ontario in Ottawa. In addition to the known metabolic effects of the drug, in clinical use “it seems to decrease eating disorder thoughts and preoccupations, and with that, resistance to taking the nutrition.” However, she noted, “there’s been little to date in terms of research in adolescents.”

One previous placebo-controlled pilot study in adolescent girls (n =20) found no differences in rate or amount of weight gain between olanzapine-treated and placebo groups (J Child Adolesc Psychopharmacol. 2011;21[3]:207-12).

Dr. Spettigue and colleagues’ study, the largest to date to look at olanzapine in this patient group, compared low-weight patients who received standard care plus olanzapine (n = 22) to those who received standard care only (n = 10), which included nutritional support and therapy. All but three patients were girls, 85% were inpatients, and median age at baseline was 15.5 years. The mean percentage of ideal body weight was 77% and 78%, respectively, for the two groups. Doses of olanzapine ranged from 2.5 mg to 7.5 mg, with most patients on 5 mg at bedtime.

Both groups showed significant weight gains across the 6-week study period. However, the intervention group saw a significantly greater rate of increase after week 3, with the olanzapine group gaining a mean 1.53 kg between weeks 3 and 4 (vs. 0.81 in the comparison group) and 2.64 kg between weeks 4 and 6 of treatment (vs. 1.51; P = .012).

Patients in the study “were told that whether they take the medication or not they need to get to their healthy weight. We taper them off once they have reached their healthy weight, and many of them end up on SSRIs alongside family therapy as part of ongoing treatment,” Dr. Spettigue said.

Secondary outcomes in the study included the Multidimensional Anxiety Scale for Children, the Eating Disorder Examination Questionnaire, and the Children’s Depression Inventory.  Both the intervention and comparison groups, which were well matched on these measures at baseline, saw decreases for anxiety (P = .27), depression (P less than .1), and eating disorders (P = .04). Between-group differences did not reach statistical significance. 

The researchers did note elevations in lipid profiles in about a third of the olanzapine-treated patients.  Dr. Spettigue said she did not find this worrisome in this patient group, who were only on the medication for a short time, but she stressed that medical monitoring was extremely important.

The W. Garfield Weston Foundation funded the study. The investigators reported no conflicts of interest.

SAN ANTONIO – Teenagers with anorexia nervosa gained weight faster when taking the atypical antipsychotic drug olanzapine, according to results from an open-label study presented at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Olanzapine is used frequently off-label in the treatment of anorexia, said Dr. Wendy Spettigue of the Children’s Hospital of Eastern Ontario in Ottawa. In addition to the known metabolic effects of the drug, in clinical use “it seems to decrease eating disorder thoughts and preoccupations, and with that, resistance to taking the nutrition.” However, she noted, “there’s been little to date in terms of research in adolescents.”

One previous placebo-controlled pilot study in adolescent girls (n =20) found no differences in rate or amount of weight gain between olanzapine-treated and placebo groups (J Child Adolesc Psychopharmacol. 2011;21[3]:207-12).

Dr. Spettigue and colleagues’ study, the largest to date to look at olanzapine in this patient group, compared low-weight patients who received standard care plus olanzapine (n = 22) to those who received standard care only (n = 10), which included nutritional support and therapy. All but three patients were girls, 85% were inpatients, and median age at baseline was 15.5 years. The mean percentage of ideal body weight was 77% and 78%, respectively, for the two groups. Doses of olanzapine ranged from 2.5 mg to 7.5 mg, with most patients on 5 mg at bedtime.

Both groups showed significant weight gains across the 6-week study period. However, the intervention group saw a significantly greater rate of increase after week 3, with the olanzapine group gaining a mean 1.53 kg between weeks 3 and 4 (vs. 0.81 in the comparison group) and 2.64 kg between weeks 4 and 6 of treatment (vs. 1.51; P = .012).

Patients in the study “were told that whether they take the medication or not they need to get to their healthy weight. We taper them off once they have reached their healthy weight, and many of them end up on SSRIs alongside family therapy as part of ongoing treatment,” Dr. Spettigue said.

Secondary outcomes in the study included the Multidimensional Anxiety Scale for Children, the Eating Disorder Examination Questionnaire, and the Children’s Depression Inventory.  Both the intervention and comparison groups, which were well matched on these measures at baseline, saw decreases for anxiety (P = .27), depression (P less than .1), and eating disorders (P = .04). Between-group differences did not reach statistical significance. 

The researchers did note elevations in lipid profiles in about a third of the olanzapine-treated patients.  Dr. Spettigue said she did not find this worrisome in this patient group, who were only on the medication for a short time, but she stressed that medical monitoring was extremely important.

The W. Garfield Weston Foundation funded the study. The investigators reported no conflicts of interest.