Who Is Seeing the Children and Teens with Mental Health Issues—and Who Is Doing the Prescribing of Psychotropic Medications?

By: Lewis First, MD, MS; Editor-in-Chief     

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          We know that there is a critical shortage of mental health services for children and teens in this country, such that primary care providers (PCPs) are called upon to often diagnose and in turn treat and follow these patients because of lack of access to psychiatrists and even psychologists and social workers.  

         So just how often are these children being managed by a PCP?  Anderson et al. (doi: 10.1542/peds.2015-0807), in a study being released this week, used a nationally representative data set to determine if children and teens from 2 to 21 years are seen in the outpatient setting for their mental health issues by PCPs, psychiatrists or psychologists and social workers and who is prescribing psychotropic medications for these patients.  More than a third of children in this database were being seen by PCPs only which may or may not surprise you.  What won’t surprise you is that more than 40% of children with attention-deficit hyperactivity disorder (ADHD) were only seen by a PCP.  These numbers may be increasing rather than decreasing as the mental health issues we uncover in our patients rise, and the mental health work force stays about the same or even decreases in the years ahead. 

How does your practice compare to the results shared in this provocative study?  What do you suggest the AAP might do to help remedy the situation? Should pediatricians be trained to prescribe psychotropic medications that go beyond an ADHD regimen more than they are currently learning how to do?  We want to know how you are dealing with the mental health problems in your practice through your response to this blog, sending us an e-letter or posting your comments on our Facebook or Twitter pages.

Related Links

• Psychotropic Medication Use and Polypharmacy in Children With Autism Spectrum Disorders
• National Trends in Psychotropic Medication Use in Young Children: 1994–2009
• Psychotropic Medication Patterns Among Youth in Foster Care

When Your Back Is Turned: ER Visits for Medication Ingestions and Unsupervised Children

By: Joann Schulte  DO, MPH; Editorial Board Member 

COD Newsroom

     Open the bottle by getting through the safety lid, dose appropriately and then have your child swallow the
pill or liquid.   It’s funny how a young child won’t do that when you or your spouse wants that to happen.   And as soon as your back is turned, it’s amazing what a child can get into and swallow.    
     But at least children are doing less unsupervised ingestions of medications   according to new research published this month in Pediatrics.  Lovegrove et al. with the Centers for Disease Control and Prevention (doi: 10.1542/peds.2015-2092) found that the estimated number of pediatric emergency room (ER) visits for unsupervised  medication exposures has declined since 2010.  The Atlanta researchers used data from the National Electronic Injury Surveillance System/Cooperative Adverse Drug Event Surveillance Project for the years 2004-2013.  Their data comes from a public health surveillance system that draws from a nationally representative sample of hospitals with at least six pediatric beds and an ER that operates 24 hours a day.  Since 2010, the number of ER visits has declined an average of 6.7% annually to an estimated total of 59,092 estimated visits in 2013.  The estimated number of visits for an unsupervised ingestion at the peak in 2010 was 75,842.
      The decline in ER visits is good news, but what the children are swallowing is still reason for concern.  Among single substance ingestions in this study, children most frequently swallowed solid prescription medications (45.9^), over the counter (OTC) solid medications (22.3%) and   liquid OTC medications (12.4%).  Nine percent of the ingestions involved more than one medication.
      Among prescription drugs, 260 different medications were swallowed by children, most frequently opioids (13.8%) and benzodiazepines (12.7%).  The OTC liquids most frequently reported were acetaminophen (32.9%), cold/cough remedies (27.5%), ibuprofen (15.7%) and diphenhydramine (15.6%).
     The CDC researchers suggested that OTC oral medications are an important topic for further prevention efforts since only four OTC medications (named in above paragraph) account for 91% of such ingestions.  Most such medications have child resistant packaging, but that packaging requires a parent or other adult to put the safety cap back on the medication and secure it after each use.   Newer products now being tested incorporate passive safety features such as flow restriction and single use packaging which can offer a secondary safety barrier.  The FDA is strongly considering the use of such packaging as a mandate on OTC liquid acetaminophen products. 
      The report showing the decline in  unsupervised pediatric ingestions is good news, but also evidence that more effort is needed to keep young children from still gaining access to medications when a supervising adult or older child is not around.

Related Links

• Medication-Related Emergency Department Visits in Pediatrics: a Prospective Observational Study 
• A Comparison of Acute Treatment Regimens for Migraine in the Emergency Department 

A Bitter Pill to Swallow: What Does the Pediatric Literature Say About Effective Pill-Swallowing Interventions?

By: Lewis First, MD, MS; Editor-in-Chief  

      Every one of us that sees patients comes across a child who will not take the

Amanda Mills phil.cdc.gov

medicine we prescribe or recommend—perhaps due to taste, perhaps because they cannot take a pill easily, or perhaps just to be oppositional.  We also often make recommendations to try to get children to be better at taking their medicine—but what is the evidence that what we recommend works? 

      Patel et al. (doi:10.1542/peds.2014-2114) dose out the results of a systematic review on this topic this week in our journal.  The authors look at studies over a 27 year span and sadly only find 4 cohort studies and one case series—all of which recommended a method found successful in that individual study. The fact that there may be limited generalizability of a particular intervention studied, or some potential bias in wanting an assessment to work are but some of the limitations identified in this interesting review.  So what method do you recommend? 

      Is it discussed in this study?  We want to hear from you on this review and any tricks you have found (evidence-based or anecdotal) that you can share with us by responding to this blog, sending us an e-letter or posting on our Facebook and Twitter pages.  

Related Links:

•  Adherence to Label and Device Recommendations for Over-the-Counter Pediatric Liquid Medications

Antipsychotic medications and foster children- what does the Vermont story teach us?

By: Lydia Furman, MD Assistant Editor 

Kathea Pinto

       In a sobering article, Rettew et al. (doi:10.1542/peds.2014-2260) examine the prescribing of antipsychotic medications to foster children on Medicaid insurance in Vermont. They surveyed prescribers, and were able to achieve a near 80% return rate in part because continued authorization of the medication was linked to survey completion. While acknowledging the inherent shortcomings of the survey approach, including potential differences between those who did and did not reply, possible social desirability bias in responses, and the self-forgiving nature of self-report, the authors were able to extract important information.  Did prescribers follow FDA guidelines and best practice guidelines? Although a small number of respondents (8.8%) were responsible for the majority (52.7%) of prescriptions, and 84.6% of these were child psychiatrists, the survey results are still highly relevant to non-psychiatrists.  Child psychiatrists not surprisingly did better than non-psychiatrists, but the results are still humbling. 

       Nationally, antipsychotic medication prescribing for children has increased with little standardized oversight or monitoring (Harrison et al J Pediatr Health Care 2012), and in many cases without appropriate or recognized indications (41.3% did not have a diagnosis for which such treatment was supported; Pathak et al Psychiatr Serv 2010). Among the most vulnerable, children in foster care with mental health problems have been previously documented to experience antipsychotic prescribing at 3x the rate of Medicaid-insured children not in foster care (Zito et al, Pediatr 2008); although this worrisome data is now 5 years old, the problem shows no evidence of abating.  Recent work shows that, “In the absence of any co-morbid conditions, ADHD-diagnosed foster care youth had more than threefold greater adjusted odds of atypical antipsychotic use than did youth enrolled in income-eligible Medicaid categories,” (Burcu et al J Child Adolesc Psychopharmacol. 2014).  This problem is even more concerning among very young children in foster care who are experiencing prolonged treatment with way “off label” psychotropic medications: 12% of foster children age 6 years and under in foster care for 1 year or more had received a psychotropic medication (either an ADHD or antipsychotic medication) and the prevalence of medication use and duration increased significantly (Psychiatr Serv 2014). Reducing overuse of second generation antipsychotics among Medicaid-enrolled children is a national priority (Saloner et al Psychiatr Serv 2014).

      Are these results generalizable and what can primary care pediatricians take home? There is good reason to act on the information here. Almost half (42.4%) of the respondents did not actually start the medication they were prescribing. This suggests that there is a huge role for personal accountability among this group of prescribers, including not continuing medications without full review of the diagnostic evaluation and re-evaluation as appropriate, engaging in discussion and ongoing monitoring in collaboration with a child psychiatrist, and strong consideration of whether continuing the medication is in the best interest of the child.  Interestingly in this survey, only 2.1% of respondents said they were unable to access psychotherapy or counselling services, effectively removing the all-too-oft heard excuse of lack of mental health care availability as a reason for medication prescribing. Most children in foster care have been exposed to abuse, neglect, interpersonal violence and other horrific conditions- medication treatment alone or as a “quick fix” is unlikely to provide the sustained help the child needs for personality development to proceed.       

      Harrison et al note that, “Many of the causes of children’s aggressive or disruptive behaviors are linked to family relationships and stressful, unpredictable home environments, which also may be violent and aggressive (National Research Council and the Institute of Medicine, 2009). Under these situations, antipsychotic medication is not an appropriate course of treatment because it does not address the underlying cause of the problem.”  (J Pediatr Health Care 2012, available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3778027/ ).   By taking the time to reevaluate rather than just refill, those of us on the front line have the potential to make a difference for the individual child. 

 

Preventing Hazardous Drug-Drug Interactions in Children

Photo Courtesy of Kathea Pinto

Editorial Board Member Joann Schulte, DO, MPH

Drug-Drug interactions remind me of Haiti.  Specifically I think of the bokor (folk medicine healer vs. witch doctor) who used to sit under the flambeau trees at an outdoor market at Deschappelles, near the compound of Albert Schweitzer Hospital. He would set out a lazy susan swirl tray of capsules and tablets arranged by color. Patients would spin it like like a Vegas roulette wheel, picking a pink one and a turquoise one or some other mixture for malaria or hypertension. The hospital staff was persistent in telling patients that you couldn't take medicine that way. But the bokor always had supplies and customers, some of whom ended up admitted to the hospital.

I think about that roulette twirl these days as I’m learning more about Drug-Drug interactions in the US in a medical toxicology fellowship at the North Texas Poison Control Center in Dallas Parkland Hospital. Bad pharmaceutical consumption out of home medicine cabinets is a common history I hear. Every week or so I see patients who jiggered up their personal suicide attempts with a combination of benzodiazepines, street drugs, opioids and alcohol. Other patients are toddlers who went candy hunting in grandmother’s purse. 

Another category of drug interactions –unintended and often undetected– occurs in US hospitals. Those Drug-Drug interactions are the focus of a study published in Pediatrics this month.

Dr. Feinstein et al. (doi: 10.1542/peds.20142015) investigated potential Drug-Drug interactions (PDDI) among almost half a million hospitalizations in 2011 in forty-three pediatric hospitals.   They classified PDDI as contraindicated (shouldn’t be used together), major (life-threatening or medical intervention needed), moderate (may change the patient’s condition or require medical intervention) and minor (limited clinical effect).  They used an administrative database to calculate the potential interactions in a retrospective cohort study.

The researchers from Colorado and Philadelphia founded that 49% of the admitted children (approximately 245,000) had one or more PDDI. A contradicted PDDI occurred in 1% of admissions.  Opioids were were involved in 25% of of all PDDI, followed by anti-infective agents (17%), neurologic agents (15%), neurological agents (15%), gastrointestinal agents (13%) and cardiovascular agents (13%).

The likelihood of PDDI exposures increased with length of hospital stay. Among infants, 21.8% were exposed to a PDDI on the first day.

The authors have done a study showing potential PDDI, not actual data and have done it using an administrative database. But their work is important because it suggests how frequent Drug-Drug interactions might be. The numbers of reported adverse drug events are much lower. In 2003, 10% of pediatric hospitalizations were reported to have included an adverse drug effect.  

In short, the work done by the Colorado and Philadelphia researchers suggests that actual prevalence of Drug-Drug interactions might be under reported. More work is needed to verify how often such Drug-Drug interactions happen. There’s a big gap between the potential 49% reported here and the actual reported 10%.

• Emergency Hospitalizations for Unsupervised Prescription Medication Ingestions by Young Children

• Interventions to Reduce Pediatric MedicationErrors: A Systematic Review