Conduct disorder is a childhood behaviour disorder that is characterized by persistent aggressive or antisocial behaviour that disrupts the child's environment and impairs his or her functioning. A proportion of children with conduct disorder have psychopathic traits. Psychopathic traits consist of a callous-unemotional component and an impulsive-antisocial component, which are associated with two core impairments. The first is a reduced empathic response to the distress of other individuals, which primarily reflects reduced amygdala responsiveness to distress cues; the second is deficits in decision making and in reinforcement learning, which reflects dysfunction in the ventromedial prefrontal cortex and striatum. Genetic and prenatal factors contribute to the abnormal development of these neural systems, and social-environmental variables that affect motivation influence the probability that antisocial behaviour will be subsequently displayed.

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The neurobiology of psychopathic traits in youths

Atypical antipsychotic medications are increasingly used for a wide range of clinical indications in diverse populations, including privately and publicly insured youth and elderly nursing home residents. These trends heighten policy challenges for payers, patients, and clinicians related to appropriate prescribing and management, patient safety, and clinical effectiveness. For clinicians and patients, balancing risks and benefits is challenging, given the paucity of effective alternative treatments. For health care systems, regulators, and policymakers, challenges include developing the evidence base on comparative risks and benefits; defining measures of treatment quality; and implementing policies that encourage evidence-based practices while avoiding unduly burdensome restrictions.

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Broadened Use Of Atypical Antipsychotics: Safety, Effectiveness, And Policy Challenges

Atypical antipsychotic medications are increasingly used for a wide range of clinical indications in diverse populations, including privately and publicly insured youth and elderly nursing home residents. These trends heighten policy challenges for payers, pa- tients, and clinicians related to appropriate prescribing and management, patient safety, and clinical effectiveness. For clinicians and patients, balancing risks and benefits is chal- lenging, given the paucity of effective alternative treatments. For health care systems, regu- lators, and policymakers, challenges include developing the evidence base on comparative risks and benefits; defining measures of treatment quality; and implementing policies that encourage evidence-based practices while avoiding unduly burdensome restrictions. (Health Affairs 28, no. 5 (2009): w770-w781 (published online 21 July 2009; 10.1377/ hlthaff.28.5.w770))

Broadened Use Of Atypical Antipsychotics: Safety, Effectiveness, And Policy

Antipsychotic Medication Prescribing Trends in Children and Adolescents

Children and adolescents involved with child welfare, especially those who are removed from their family of origin and placed in out-of-home care, often present with complex and serious physical, mental health, developmental, and psychosocial problems rooted in childhood adversity and trauma As such, they are designated as children with special health care needs There are many barriers to providing high-quality comprehensive health care services to children and adolescents whose lives are characterized by transience and uncertainty Pediatricians have a critical role in ensuring the well-being of children in out-of-home care through the provision of high-quality pediatric health services in the context of a medical home, and health care coordination and advocacy on their behalf This technical report supports the policy statement of the same title

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Health Care Issues for Children and Adolescents in Foster Care and Kinship Care

CONTEXT. Studies have revealed that youth in foster care covered by Medicaid insurance receive psychotropic medication at a rate >3 times that of Medicaid-insured youth who qualify by low family income. Systematic data on patterns of medication treatment, particularly concomitant drugs, for youth in foster care are limited. OBJECTIVE. The purpose of this work was to describe and quantify patterns of psychotropic monotherapy and concomitant therapy prescribed to a randomly selected, 1-month sample of youth in foster care who had been receiving psychotropic medication. METHODS. Medicaid data were accessed for a July 2004 random sample of 472 medicated youth in foster care aged 0 through 19 years from a southwestern US state. Psychotropic medication treatment data were identified by concomitant pattern, frequency, medication class, subclass, and drug entity and were analyzed in relation to age group; gender; race or ethnicity; International Classification of Diseases, Ninth Revision, psychiatric diagnosis; and physician specialty. RESULTS. Of the foster children who had been dispensed psychotropic medication, 41.3% received ≥3 different classes of these drugs during July 2004, and 15.9% received ≥4 different classes. The most frequently used medications were antidepressants (56.8%), attention-deficit/hyperactivity disorder drugs (55.9%), and antipsychotic agents (53.2%). The use of specific psychotropic medication classes varied little by diagnostic grouping. Psychiatrists prescribed 93% of the psychotropic medication dispensed to youth in foster care. The use of ≥2 drugs within the same psychotropic medication class was noted in 22.2% of those who were given prescribed drugs concomitantly. CONCLUSIONS. Concomitant psychotropic medication treatment is frequent for youth in foster care and lacks substantive evidence as to its effectiveness and safety.

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Devadatta Sai

Papers

Psychotropic medication patterns among youth in foster care.