Psychotropic Medication Use Among Young Children Aged 2–5 Years
28th Annual Children’s Mental Health Policy and Research Conference, March 25, 2015
Susan Drilea, M.S.; Emily Madden, B.B.A.; Russell Carleton, Ph.D., Kurt Moore, Ph.D., Christopher Duckworth, M.P.H., and Keri Jowers, Ph.D.
Funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) through the Child, Adolescent and Family Branch, Center for Mental Health Services
2
Introduction
• Psychotropic medication has been increasingly prescribed to young children, ages 2‐5 years1
• Among all young children, 1%‐2% take psychotropic medication2
• Among young children with behavioral and emotional problems, 12%‐16% take psychotropic medication3
• Side effects include sleep problems, decreased appetite, delayed growth, agitation, weight gain, obesity, hypertension, lipid and glucose abnormalities, movement disorders, and sedation4
• Little is known about the effectiveness of these medications among young children
1 Chirdkiatgumchai, et al., 2013; Olfson, Blanco, Liu, Moreno, & Laje, 2006. Zito, et al. 2000. 2 Chirdkiatgumchai, et al., 2013; Olfson M, Crystal S, Huang C, Gerhard T, 2010. 3 DeBar, L.L., Lynch, F., Powell, J, Gale, J., 2003; dosReis S, et al. 2014
4 Correll, et al., 2009; Garcia, et al., 2012; Zito, et al. 2008
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Research Questions
1) Are there differences between young children with emotional and behavioral problems who take psychotropic medication and those who do not?
2) Which psychotropic medications do young children take? 3) What is the association between psychotropic medication use and changes in emotional and behavioral symptoms within the first 6 months of receiving system of care services? 4
Methods
• Secondary analysis of data from the national evaluation of the Children’s Mental Health Initiative (CMHI) • Cross‐Sectional Descriptive Study
• Longitudinal Child and Family Outcome Study
• Data collected through August 2014 by 106 CMHI grantees initially funded by SAMHSA in 2002–2010
5
System of Care Grantees of the Comprehensive
Community Mental Health Services for Children and
Their Families Program
Funded
Communities
Date
Number
1993–1994
1997–1998
1999–2000
2002–2004
2005–2006
2008
2009–2010
22
23
22
29
30
18
29
6
Methods (continued)
• Data collected
– At intake (child characteristics, diagnosis, severity of illness)
– At 6‐month follow‐up (medication use, clinical outcomes)
• DSM–IV–TR, Axis I or DC:0–3 Revised, Axis I
• Child Behavior Checklist (CBCL), Total Problems score
• Analyses
– Reliable Change Index (RCI)
– ANOVA
– Multilevel Mixed‐Effects Logistic Regression
– Multilevel Mixed‐Effects Linear Regression
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Psychotropic Medication Use by Demographic Characteristics
Total Sample
Took No Medication
Took Medication
1,662
75.2 %
24.8 %
Boys
1,099
71.5 %
28.5 %
Girls
562
82.4 %
17.6 %
2 Years
235
95.7 %
4.3 %
3 Years
427
86.2 %
13.8 %
4 Years
501
76.0 %
24.0 %
5 Years
499
55.1 %
44.9 %
Total
p
Gender
<.001
Age <.001
8
Psychotropic Medication Use by Demographic Characteristics (continued)
Total Sample
Took No Medication
Took Medication
p
American Indian or Alaska Native
39
79.5 %
20.5 %
<.001
Asian
28
96.4 %
3.6 %
Black or African American
254
72.0 %
28.0 %
Native Hawaiian or Pacific Islander
59
94.9 %
5.1 %
White
706
67.8 %
32.2 %
Hispanic/Latino
433
86.6 %
13.4 %
Multi‐Racial and Other
125
66.5 %
33.5 %
Below Poverty
939
74.5 %
25.5 %
At/Near Poverty
215
72.6 %
27.4 %
Above Poverty
331
72.2 %
27.8 %
Race/Ethnicity
Poverty Level
.646
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Psychotropic Medication Use by Diagnosis and Symptom Severity
Total Sample
Took No Medication
Took Medication
Attention‐Deficit/Hyperactivity (ADHD)
257
31.1 %
68.9 %
Mood Disorders
106
46.2 %
53.8 %
Oppositional Defiant Disorder (ODD)
132
50.8 %
49.2 %
Disruptive Behavior Disorders (DBD)
292
74.7 %
25.3 %
Anxiety Disorders
228
81.6 %
18.4 %
Adjustment Disorder
488
87.7 %
12.3 %
1,619
66.01 (11.10)
72.46 ( 9.82)
548
86.7 %
13.3 %
1,071
69.5 %
30.5 %
Most Common Diagnostic Categories1
Symptom Severity at Intake
CBCL2 Total Problems Score, M (SD)
Below Clinical Level
At/Above Clinical Level
1 Children
may be diagnosed with more than one DSM-IV or DC:0-3 category.
Child Behavior Checklist 1½-5. Scores from the CBCL 1½-5 Total Problems scale between 60 and 63 are in the
borderline clinical range; scores of 64 and higher are in the clinical range.
2
10
Most Frequently Taken Medications by Medication Class
Most Frequently Taken Medications1
Medication Classes
n
1st
2nd
3rd
Psychostimulants2
202
Adderall (32.7%)
Concerta (22.8%)
Ritalin (11.9%)
Antidepressants3
12
Prozac (66.8%)
Zoloft (25.0%)
Paxil (8.3%)
Anticonvulsants4
11
Depakote (63.6%)
Trileptal (18.2%)
Lamictal (18.2%)
Anxiolytics5
1
Antipsychotics6
84
Abilify (17.9%)
Seroquel (11.9%)
Antimanics7
3
Antihypertensives8
70
‐‐
Risperdal (69.1%)
‐‐
Tenex (51.4%)
Catapres (48.6%)
1 Children
may have taken more than one medication, sequentially or concurrently.
Includes Adderall, Ritalin, Concerta, Focalin, Celexa, Daytrana, Desyrel, Metadate, Strattera, Vyvanse
3 Includes Effexor, Zoloft, Lexapro, Paxil, Prozac, Remeron, Tofranil, Wellbutrin, Anafranil
4 Includes Depakote, Lamictal, Neurontin, Tegretol, Trileptal
5 Includes Klonopin, Valium
6 Includes Risperdal, Abilify, Seroquel, Zyprexa, Geodon
7 Includes Eskalith, Lithobid, Lithonate
8 alpha-2 adrenergic receptor agonists. Includes Catapres, Tenex
-- Represents data for fewer than 10 children; data are not shown to protect confidentiality.
2
11
Medication Class by Diagnosis
Most Common Medication Classes
Most Common Diagnostic Categories1
1st
2nd
3rd
Attention‐Deficit/Hyperactivity (ADHD)
Psychostimulants
Antipsychotics
Antihypertensives
Mood Disorders
Antipsychotics
Psychostimulants
Anticonvulsants
Oppositional Defiant Disorder (ODD)
Psychostimulants
Antipsychotics
Antihypertensives
Disruptive Behavior Disorders (DBD)
Psychostimulants
Antihypertensives
Antipsychotics
Anxiety Disorders
Psychostimulants
Antipsychotics
Antihypertensives
Adjustment Disorder
Psychostimulants
Antipsychotics
Antihypertensives
1 Children
may have more than one diagnosis
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Change in CBCL Total Problems Scores, Intake to 6 Months
Reliable Change Index Comparing CBCL Total Problems Scores between Intake and 6 Months among Children Aged 2–5 Years
100%
90%
Percentage
80%
33.3%
26.7%
70%
60%
Improved
50%
40%
30%
59.8%
64.1%
Remained Stable
Worsened
20%
10%
0%
6.8%
9.2%
Took No Medication
Took Medication
1
The Reliable Change Index (RCI) is a relative measure that compares scores at two different points in time and indicates whether a change in score shows significant improvement, worsening, or stability (i.e., no significant change).
13
Change in Symptom Severity,
Intake to 6 Months
n
Mean Score (SD)
p
< .001
Total Sample
Intake
1,591
67.63 (11.11)
6 Months
1,591
63.70 (11.60)
Intake
1,198
66.03 (11.05)
6 Months
1,198
61.77 (11.53)
Intake
393
72.49 ( 9.81)
6 Months
393
69.58 ( 9.71)
1,198
‐4.27 ( 9.03)
393
‐2.91 ( 8.13)
Took No Medication
< .001
Took Medication
< .001
Change in Mean Total Problem Score
Took No Medication
Took Medication
.005
1
Child Behavior Checklist. Scores from the CBCL Total Problems scale between 60 and 63 are in
the borderline clinical range; scores of 64 and higher are in the clinical range.
14
Multilevel Mixed‐Effects Logistic Regression Multivariate Associations between Medication Use and Child Characteristics
OR
95% CI
p
Age (years)
2.272
(1.937, 2.665)
< .001
Gender (reference =male)
0.541
(0.397, 0.737)
< .001
Black or African‐American
0.970
(0.656, 1.434)
.878
Hispanic
0.351
(0.238, 0.520)
< .001
Other
0.818
(0.349, 1.918)
.644
Above Poverty
0.940
(0.676, 1.307)
.712
Symptom Severity at Intake
1.069
(1.054, 1.084)
< .001
Race (reference=white)
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Multilevel Mixed‐Effects Logistic Regression
Multivariate Associations between Clinical Impairment and Medication Use,
Controlling for Other Child Characteristics
Odds Ratio
SE (B)
95% CI
p
Taking Medication
1.884
0.336
(1.328, 2.673)
<.001
Age (years)
0.938
0.066
(.8177, 1.075)
.357
Gender (reference=male)
0.846
0.121
(.638, 1.121)
.357
Black or African‐American
0.698
0.133
(.480, 1.014)
.059
Hispanic
0.882
0.147
(.637, 1.222)
.450
Other
0.653
0.248
(.310, 1.374)
.261
Above Poverty
1.037
0.170
(.752, 1.430)
.823
Co‐Occurring Diagnoses
1.432
0.146
(1.172, 1.750)
<.001
Symptom Severity at Intake
1.173
0.011
(1.151, 1.193)
<.001
Race (reference=white)
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Multilevel Mixed‐Effects Linear Regression
Multivariate Associations between Change in CBCL Total Problems Score and
Medication Use, Controlling for Other Child Characteristics
B
SE (B)
95% CI
p
Taking Medication
2.677
0.559
(1.581, 3.772)
<.001
Age (years)
‐0.104
0.222
(‐0.539, 0.331)
.641
Gender (reference=male)
‐0.540
0.459
(‐1.438, 0.359)
.239
Black or African‐American
‐1.085
0.614
(‐2.288, 0.118)
.077
Hispanic
‐1.137
0.529
(‐2.174, ‐0.100)
.032
Other
‐2.444
1.130
(‐4.659, ‐0.228)
.031
Above Poverty
0.172
0.524
(‐0.854, 1.199)
.742
Co‐Occurring Diagnoses
.918
0.309
(0.313, 1.525)
.003
Symptom Severity at Intake
.697
0.020
(0.657, 0.737)
<.001
Race (reference=white)
17
Limitations and Considerations
• Findings represent associations, not causal relationships.
• Some data are based on medical records review, most based on caregiver report.
• All children in this sample were also receiving other mental health services.
• Diagnostic profile of children taking medications differs from those not taking medication. • Data on medication use do not identify when medication was actually started, duration taken, dose, how taken, or compliance.
• Data on medication use represent medication actually taken, not medication prescribed.
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Conclusions
Medication Use
• Among children ages 2–5 years diagnosed with emotional and behavioral challenges, 25 percent took psychotropic medication, on average.
• Those most likely to take medication included boys, those age 5 years, and those who were White or multi‐racial.
• Those diagnosed with ADHD were the most likely to take psychotropic medication.
• Most commonly taken medication classes included psychostimulants, antipsychotics, and antihypertensives. • Controlling for all characteristics, age, gender, and symptom severity at intake predicted medication use. 19
Conclusions (continued)
Emotional and Behavioral Symptoms
• Mean CBCL scores at intake were above clinical level for both groups; scores for both groups showed improvement between intake and 6 months.
• Children taking medication showed less symptom improvement than those not taking medication.
• Mean CBCL scores remained above clinical level at 6 months among those taking medication. • Higher CBCL scores at intake were associated with higher symptom severity at 6 months.
• Controlling for initial symptom severity, taking medication predicts higher CBCL scores (less improvement) at 6 months than not taking medication. 20
References
Chirdkiatgumchai , V., Xiao ,H., Fredstrom, B.K., Adams , R.E., Epstein, J.N., Shah, S.S., Brinkman, W.B., Kahn, R.S., & Froehlich, T.E. (2013). National trends in psychotropic medication use in young children: 1994‐2009. Pediatrics; 132(4):615‐23.
Correll, C. U., Manu, P., Olshanskiy, V., Napolitano, B., Kane, J. M., & Malhotra, A. K. (2009, October 28). Cardiometabolic risk of second‐generation antipsychotic medications during first‐time use in children and adolescents. Journal of the American Medical Association, 302(16), 1765‐1773.
DeBarr LL, Lynch F, Powell J, Gale J. (2003). Use of psychotropic agents in preschool children: associated symptoms, diagnoses, and health care services in a health maintenance organization.
Arch Pediatr Adolesc Med. Feb;157(2):150‐7.
dosReis S, Tai MH, Goffman D, et al., (2014). Age‐related trends in psychotropic medication use among
very young children in foster care. Psychiatr Serv. Aug 1, Garcia, G., Logan, G.E., Gonzalez‐Heydrich, J. (2012). Management of psychotropic medication side effects in children and adolescents. Child Adolesc Psychiatr Clin N Am. Oct;21(4):713‐38. Olfson, M., Blanco, C., Liu, L., Moreno, C., & Laje, G. (2006). National trends in the outpatient treatment of children and adolescents with antipsychotic drugs. Archives of General Psychiatry, 63, 679‐685.
Olfson, M., Crystal, S., Huang, C., & Gerhard, T. (2010). Trends in antipsychotic drug use by very young, privately insured children. Journal of the American Academy of Child and Adolescent Psychiatry, 49(1), 13‐23. Zito, J.M., Derivan, A.T., Dratochvil, C.J., et al. (2008)Off‐label psychopharmacologic prescribing for children:
History supports close clinical monitoring. Child and Adolescent Psychiatry and Mental Health, 2:24.
Zito, J.M., Safer, D.J., dosReis, S., Gardner, J.F., Boles, M., Lynch, F. (2000). Trends in the prescribing of psychotropic medications to preschoolers. JAMA; 283(8):1025‐30. 21
Contact Information
Susan Drilea, M.S.; WRMA, Rockville, MD; [email protected]; (301) 881-2590,
ext. 224
Emily Madden, B.B.A.; WRMA, Rockville, MD; [email protected]; (301) 8812590
Russell Carleton, Ph.D.; ICF International, Atlanta, GA; [email protected];
(404) 592-2130
Kurt Moore, Ph.D.; WRMA, Denver, CO; [email protected]; (916) 239-4020, ext.
409
Christopher Duckworth, M.P.H.; Eastern Kentucky University, Richmond, KY;
[email protected]; (859) 622-7284
Keri Jowers, Ph.D.; Maryland State Department of Education, Baltimore, MD;
[email protected]; (443) 365-1051
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