Comparing pregnancy and pregnancy outcome rates between adolescents with and without pre-existing mental disorders.

BACKGROUND: There are limited population-based data on the role of mental disorders in adolescent pregnancy, despite the presence of mental disorders that may affect adolescents' desires and decisions to become pregnant. OBJECTIVE: This study aimed to examine the relationship between specific types of mental disorders and pregnancy rates and outcome types among adolescents aged 13-19 years, using single-year age groups. METHODS: We conducted a retrospective cohort study using data from the Merative™ MarketScan Research Databases. The study population consisted of females aged 13-19 years with continuous insurance enrollment for three consecutive calendar years between 2005 and 2015. Pregnancy incidence rates were calculated both overall and within the different categories of mental disorders. The presence of mental disorders, identified through diagnosis codes, was classified into 15 categories. Pregnancy and pregnancy outcome types were determined using diagnosis and procedure codes indicating the pregnancy status or outcome. To address potential over- or underestimations of mental disorder-specific pregnancy rates resulting from variations in age distribution across different mental disorder types, we applied age standardization using 2010 U.S. Census data. Finally, multivariable logistic regression models were used to examine the relationships between 15 specific types of mental disorders and pregnancy incidence rates, stratified by age. RESULTS: The age-standardized pregnancy rate among adolescents diagnosed with at least one mental disorder was 15.4 per 1,000 person-years, compared to 8.5 per 1,000 person-years among adolescents without a mental disorder diagnosis. Compared to pregnant adolescents without a mental disorder diagnosis, those with a mental disorder diagnosis had a slightly but significantly higher abortion rate (26.7% vs 23.8%, P-value < 0.001). Multivariable logistic regression models showed that substance use-related disorders had the highest odds ratios (ORs) for pregnancy incidence, ranging from 2.4 [95% confidence interval (CI): 2.1-2.7] to 4.5 [95% CI:2.1-9.5] across different age groups. Overall, bipolar disorders (OR range: 1.6 [95% CI:1.4-1.9]- 1.8 [95% CI: 1.7-2.0]), depressive disorders (OR range: 1.4 [95% CI: 1.3-1.5]- 2.7 [95% CI: 2.3-3.1]), alcohol-related disorders (OR range: 1.2 [95% CI: 1.1-1.4]- 14.5 [95% CI: 1.2-178.6]), and attention-deficit/conduct/disruptive behavior disorders (OR range: 1.1 [95% CI: 1.0-1.1]- 1.8 [95% CI: 1.1-3.0]) were also significantly associated with adolescent pregnancy, compared to adolescents without diagnosed mental disorders of the same age. CONCLUSION: This study emphasizes the elevated rates of pregnancy and pregnancy ending in abortion among adolescents diagnosed with mental disorders, and identifies the particular mental disorders associated with higher pregnancy rates.

An open label pilot trial of sequential bifrontal low frequency r-TMS in the treatment of primary insomnia.

This pilot study examines the therapeutic effects of bifrontal low frequency (LF) TMS on primary insomnia. In this prospective, open-label study 20 patients with primary insomnia and without major depressive disorder received 15 sequential bifrontal LF rTMS stimulation sessions. By week 3, PSQI scores declined from baseline score of 12.57(sd 2.74) to 9.50 (sd 4.27), a large effects size (0.80 (CI 0.29, 1.36)), and CGI-I scores improved for 52.6% of participants. Results of this pilot indicate that the novel bifrontal LF rTMS benefitted this group of patients suffering from primary insomnia, with absence of sham control a significant study limitation.

Use of Acute Mental Health Care in U.S. Children's Hospitals Before and After Statewide COVID-19 School Closure Orders.

Objective: This study aimed to examine changes in child emergency department (ED) discharges and hospitalizations for primary general medical (GM) and primary psychiatric disorders; prevalence of psychiatric disorders among acute care encounters; and change in acute mental health (MH) care encounters by disorder type and, within these categories, by child sociodemographic characteristics before and after statewide COVID-19­related school closure orders. Methods: This retrospective, cross-sectional cohort study used the Pediatric Health Information System database to assess percent changes in ED discharges and hospitalizations (N=2,658,474 total encounters) among children ages 3­17 years in 44 U.S. children's hospitals in 2020 compared with 2019, by using matched data for 36- and 12-calendar-week intervals. Results: Decline in MH ED discharges accounted for about half of the decline in ED discharges and hospitalizations for primary GM disorders (−24.8% vs. −49.1%), and MH hospitalizations declined 3.4 times less (−8.0% vs. −26.8%) in 2020. Suicide attempt or self-injury and depressive disorders accounted for >50% of acute MH care encounters before and after the statewide school closures. The increase in both ED discharges and hospitalizations for suicide attempt or self-injury was 5.1 percentage points (p<0.001). By fall 2020, MH hospitalizations for suicide attempt or self-injury rose by 41.7%, with a 43.8% and 49.2% rise among adolescents and girls, respectively. Conclusions: Suicide or self-injury and depressive disorders drove acute MH care encounters in 44 U.S. children's hospitals after COVID-19­related school closures. Research is needed to identify continuing risk indicators (e.g., sociodemographic characteristics, psychiatric disorder types, and social determinants of health) of acute child MH care.

Mental Health-Related Emergency Department Visits Among Children During The Early COVID-19 Pandemic.

Objective: To measure univariate and covariate-adjusted trends in children's mental health-related emergency department (MH-ED) use across geographically diverse areas of the U.S. during the first wave of the Coronavirus-2019 (COVID-19) pandemic. Method: This is a retrospective, cross-sectional cohort study using electronic health records from four academic health systems, comparing percent volume change and adjusted risk of child MH-ED visits among children aged 3-17 years, matched on 36-week (3/18/19-11/25/19 vs. 3/16/20-11/22/20) and 12-week seasonal time intervals. Adjusted incidence rate ratios (IRR) were calculated using multivariate Poisson regression. Results: Visits declined during spring-fall 2020 (n = 3892 vs. n = 5228, -25.5%) and during spring (n = 1051 vs. n = 1839, -42.8%), summer (n = 1430 vs. n = 1469, -2.6%), and fall (n = 1411 vs. n = 1920, -26.5%), compared with 2019. There were greater declines among males (28.2% vs. females -22.9%), children 6-12-year (-28.6% vs. -25.9% for 3-5 years and -22.9% for 13-17 years), and Black children (-34.8% vs. -17.7% to -24.9%). Visits also declined for developmental disorders (-17.0%) and childhood-onset disorders (e.g., attention deficit and hyperactivity disorders; -18.0%). During summer-fall 2020, suicide-related visits rose (summer +29.8%, fall +20.4%), but were not significantly elevated from 2019 when controlling for demographic shifts. In contrast, MH-ED use during spring-fall 2020 was significantly reduced for intellectual disabilities (IRR 0.62 [95% CI 0.47-0.86]), developmental disorders (IRR 0.71 [0.54-0.92]), and childhood-onset disorders (IRR 0.74 [0.56-0.97]). Conclusions: The early pandemic brought overall declines in child MH-ED use alongside co-occurring demographic and diagnostic shifts. Children vulnerable to missed detection during instructional disruptions experienced disproportionate declines, suggesting need for future longitudinal research in this population.

Florida Medicaid Children's Receipt of First-Line Psychosocial Care Prior to Antipsychotic Initiation.

BACKGROUND AND OBJECTIVE: First-line, nonpharmacological therapy is recommended for many pediatric mental health (MH) conditions prior to initiating antipsychotic prescription therapies. Many children do not receive these recommended services, despite the known association between antipsychotic medications and metabolic dysfunction. The main objective of this study was to quantify the association among children's MH diagnosis categories, sociodemographic characteristics and receipt of first-line psychosocial care among children in Florida Medicaid METHODS: Florida Medicaid enrollment, healthcare and pharmacy claims were used for this multivariate analysis. Children were assigned to condition clusters wherein related diagnoses were grouped into clinically relevant categories. A total of 7704 children were included in the final analysis. RESULTS: Twenty-four percent of children in Florida Medicaid do not receive first-line, nonpharmacological psychosocial care. Age was significantly associated with not receiving psychosocial services, with older children less likely to receive. Non-Hispanic White children as well as those living in rural areas had lower odds of receiving behavioral intervention prior to initiating antipsychotics. Children with mood-disorders, behavior problems, anxiety and stress related disorders were more likely to receive first-line psychosocial care. CONCLUSIONS: This study provides an important understanding of the variability in receipt of first-line psychosocial care before antipsychotic medication initiation among children in Medicaid based on sociodemographic and MH health characteristics. These analyses can be used to develop quality improvement initiatives targeted toward children that are most vulnerable for not receiving recommended care.

Enhancing Quality Measurement With Clinical Information: A Use Case of Body Mass Index Change Among Children Taking Second Generation Antipsychotics.

OBJECTIVE: We sought to examine the extent to which body mass index (BMI) was available in electronic health records for Florida Medicaid recipients aged 5 to 18 years taking Second-Generation Antipsychotics (SGAP). We also sought to illustrate how clinical data can be used to identify children most at-risk for SGAP-induced weight gain, which cannot be done using process-focused measures. METHODS: Electronic health record (EHR) data and Medicaid claims were linked from 2013 to 2019. We quantified sociodemographic differences between children with and without pre- and post-BMI values. We developed a linear regression model of post-BMI to examine pre-post changes in BMI among 4 groups: 1) BH/SGAP+ children had behavioral health conditions and were taking SGAP; 2) BH/SGAP- children had behavioral health conditions without taking SGAP; 3) children with asthma; and 4) healthy children. RESULTS: Of 363,360 EHR-Medicaid linked children, 18,726 were BH/SGAP+. Roughly 4% of linked children and 8% of BH/SGAP+ children had both pre and post values of BMI required to assess quality of SGAP monitoring. The percentage varied with gender and race-ethnicity. The R2 for the regression model with all predictors was 0.865. Pre-post change in BMI differed significantly (P < .0001) among the groups, with more BMI gain among those taking SGAP, particularly those with higher baseline BMI. CONCLUSION: Meeting the 2030 Centers for Medicare and Medicaid Services goal of digital monitoring of quality of care will require continuing expansion of clinical encounter data capture to provide the data needed for digital quality monitoring. Using linked EHR and claims data allows identifying children at higher risk for SGAP-induced weight gain.

Establishing norms on the Japanese version of the Eyberg Child Behavior Inventory.

BACKGROUND: The Eyberg Child Behavior Inventory (ECBI) is one of the standardized parent rating scales used to identify disruptive behavior problems in children in Western countries. This study aimed to determine norms for the Japanese version of the ECBI, including clinical cutoff scores among the general population in Japan. METHODS: This study established norms for the Japanese version of the ECBI using a sample of 1,992 parents of children aged 2-7, living in Japan. The research evaluates the validity and the reliability of the ECBI scores for the Intensity Scale and the Problem Scale. After validation, a clinical cutoff value of the ECBI scores was calculated, setting the cutoff to above the +1 standard deviation (SD) level based on the population distribution. RESULTS: The means of the Intensity and Problem Scale scores were 100.07 and 6.57, respectively. Cronbach's α for both the Intensity and the Problem scores was 0.91. At this point, we propose cutoff scores of 125 for the Intensity Scale and 14 for the Problem Scale. CONCLUSIONS: Our results suggest that the Japanese version of the ECBI is highly reliable and may be useful as a tool for assessing behavior problems in children.

Therapeutic Horticulture as a Therapeutic Intervention in Patients Receiving Electroconvulsive Therapy (ECT) Treatment for Major Depressive Disorder.

This study explored the effect of a structured therapeutic horticulture (TH) program on depression symptoms and quality of life indicators for individuals receiving inpatient electroconvulsive therapy (ECT) for major depressive disorders (MDD). Self-reported measures of depressive symptomatology (PHQ9, BDI-II) and quality of life (SF-36) were employed to compare intervention (n = 25) and control groups (n = 27), with the intervention group attending TH sessions for one-hour periods, twice per week, in addition to standard inpatient care associated with ECT received by both groups. All patients were assessed at admission, and after two weeks' time or prior to discharge, during which the intervention group participated in a minimum of four TH sessions. Sessions were led by a horticultural therapist in an accessible on-campus greenhouse. Both groups improved significantly between assessment times one and two on both measures of depression, with a statistically significant difference in change scores for the BDI-II only, favoring the control over the intervention group (16.5, s.d. 12.78 versus 9.6, s.d. 10.15; p = 0.36). Both groups improved significantly on four of eight SF-36 subscales during the same period. A statistically significant difference in change scores was found for the Role Limitations-Physical Health (RLPH) subscale, where the intervention group improved between assessment periods, whereas the control group worsened (16.0, s.d.48.8 versus -9.3, s.d. 33.4; p = .033). Although quantifying group changes or improvement for individuals receiving intensive treatment for major depressive disorders (ECT) by the addition of an adjunct therapy is difficult, this study provides a basic premise for the consideration of various therapeutic horticulture settings to achieve therapeutic benefits through TH.

The Interactive Effect of Social Capital and Duration of Migration on Suicidal Behaviors Among Rural-to-Urban Migrants in China: Evidence from a GIS/GPS-Assisted Probability Sample.

Suicide for rural-to-urban migrants in China presents a challenge. Social capital as a modifiable factor is associated with suicidal behaviors at different levels for different populations. This study focuses on the social capital-suicidal behavior relationship among rural migrants with detailed social capital measures and their interaction with migration duration. Data were collected from a rural migrant sample in Wuhan, China. Outcome variable was reported suicidal ideation and attempts in the past 12 months. Social capital was measured using the Personal Social Capital Scale. Year of migration was measured as the number of years a subject migrated to the city. Multivariate logistic regression (coefficients [95%CIs]) was used for data analysis. Time of crossover for interaction was estimated as the year when the effect of social capital on a suicidal behavior revered from negative to positive. Study findings show a negative association between social capital and suicidal ideation (-1.48 [-2.86, -0.10]), but the association was not significant for suicidal attempts (-1.30 [-2.68, 0.08]) after considering the positive interaction between social capital and year of migration (0.11 [0.03, 0.19] for ideation and 0.11 [0.02, 0.19] for attempts). Similar effects were found for detailed social capital measures. The estimated time of crossover ranged from 7.0 to 14.8 years for different social capital measures. The findings of this study confirm the protective relationship between social capital and suicidal behaviors in the early years of migration among rural migrants. These findings inform suicide prevention among rural migrants by considering social capital during the first 7 to 15 years of migration.

Age moderated-anxiety mediation for multimodal treatment outcome among children with obsessive-compulsive disorder: An evaluation with correspondence analysis.

INTRODUCTION: Anxiety expression varies by age in youth, and evaluation of putative mechanisms in treatment must consider both conjointly. Accordingly, age would moderate the mediation effect of anxiety in a youth obsessive-compulsive disorder (OCD) treatment trial. METHODS: Fifty-six children ages 7 - 17 participated in an RCT comparing three treatments: CBT with standard dosing of sertraline, CBT with slow dosing of sertraline, and CBT with placebo. To examine the moderated-mediation effects for OCD symptom improvement, we discretized the continuous anxiety and OCD measures into three symptom outcome categories, "improved", "unchanged", and "deteriorated". To evaluate the moderating effect of age, we further examined the association of age and anxiety with the "improved" OCD category. For analysis, the age groups used as rows were cross tabulated with discretized anxiety and OCD measures. To estimate category associations with correlations, we adopted correspondence analysis. RESULTS: The correlational results indicate that for all treatment conditions, age was a moderator of the mediation effect of physical anxiety symptoms for the improved OCD measures (outcomes). Specifically, age suppressed correlations with OCD outcomes, with Physical Symptoms as a mediator for the outcome measures. This moderated mediation effect was most evident for ages 8-10 in the CBT with placebo group. LIMITATIONS: The moderated mediation effect manifest in this single RCT-based study should be validated in other studies. DISCUSSION: Future research investigating a wider range of ages as a potential moderator of other symptom and emotion mediators of outcome is warranted, particularly in relation to individual symptom profiles of OCD.

Provider Specialty and Receipt of Metabolic Monitoring for Children Taking Antipsychotics.

BACKGROUND AND OBJECTIVES: Metabolic monitoring is important for children taking antipsychotic medication, given the risk for increased BMI, impaired glucose metabolism, and hyperlipidemia. The purpose was to examine the influence of provider specialty on the receipt of metabolic monitoring. Specifically, differences in the receipt of recommended care when a child receives outpatient care from a primary care provider (PCP), a mental health provider with prescribing privileges, or both was examined. METHODS: Medicaid enrollment and health care and pharmacy claims data from 2 states were used in the analyses. Providers were assigned to specialties by using a crosswalk of the National Provider Identifier numbers to specialty type. A total of 41 078 children were included. RESULTS: For both states, 61% of children saw ≥1 provider type and had adjusted odds ratios for receiving metabolic monitoring that were significantly higher than those of children seeing PCPs only. For example, children seeing a PCP and a mental health provider with prescribing privileges during the year had adjusted odds of receiving metabolic monitoring that were 42% higher than those seeing a PCP alone (P < .001). CONCLUSIONS: Shared care arrangements significantly increased the chances that metabolic monitoring would be done. For states, health plans, and clinicians to develop meaningful quality improvement strategies, identifying the multiple providers caring for the children and potentially responsible for ordering tests consistent with evidence-based care is essential. Provider attribution in the context of shared care arrangements plays a critical role in driving quality improvement efforts.

Editorial: Trials and Tribulations of Developing Adolescent Attention-Deficit/Hyperactivity Disorder Interventions: Digging Deep to Stay Motivated.

Attention-deficit/hyperactivity disorder (ADHD) has great public health relevance due to its high prevalence; adverse academic, social, economic, and health impacts on affected individuals and their families; and well established psychosocial and pharmacological treatment options.1 Typically presenting with childhood onset, ADHD remains an impairing disorder through adolescence to adulthood for a majority of those affected. It is well established that adolescents with any chronic health condition are difficult to engage in protracted illness management, with an estimated 50%-80% struggling with nonadherence, prompting significant efforts to identify adherence promotion interventions.2 Transition-age youth with ADHD are no exception, especially as it pertains to medication use.3 Indeed, ADHD intervention development for transition ages represents a high public health priority, as signaled through grant opportunities offered by the NIMH for pilot projects to refine and test interventions to sustain ADHD treatment effects across developmental transitions (see https://grants.nih.gov/grants/guide/rfa-files/RFA-MH-20-100.html).

Editorial: Parental Depression Does Not Impede Benefits From Behavioral Parent Training.

Behavioral parent training (BPT) programs are considered the gold standard for intervening in early-onset conduct disorders.1 Our understanding of the disorder etiology has evolved from a focus on the coercive parent-child interaction to include more complex considerations, including gene-environment interactions.2 Refining our understanding of prevention and early intervention for these common and costly disorders is an important public health priority, because an estimated 3% of children and their families are affected, compromising adolescent and adult outcomes.2 As detailed in a recent review, the five most well-established BPTs, including the Incredible Years Series, contain common elements (use of didactics; modeling; role playing; and homework practice) and theoretical underpinnings (eg, social learning; attachment).3 Furthermore, they share the common bond of academic mentorship in the 1960s and 1970s. These BPT programs are referred to as "Hanf-Model BPT programs" in recognition of developers' influential faculty teacher, Dr. Constance Hanf, from the University of Oregon, Child Development and Rehabilitation Center.3.

Quality of Evidence Supporting Major Psychotropic Drug-Drug Interaction Warnings: A Systematic Literature Review.

Among pharmacodynamic and pharmacokinetic drug-drug interactions (DDIs), psychotropic drug-drug interactions (pDDIs) are of particular interest because psychopharmacologic agents mark one of the fastest growing therapeutic drug classes over the past 2 decades, and prescribing multiple psychotropic drugs has become increasingly prevalent in clinical practice. However, the documentation of pDDIs across drug references has lacked consistency. Thus we set out to review the primary evidence directly supporting 58 pDDIs that were uniformly reported as "major" or "contraindicated" in three prominent drug references: Clinical Pharmacology, Micromedex, and Lexicomp. We identified 134 citations from Micromedex in December 2017 and 4251 citations from Medline in March 2018 involving any of the 58 pDDIs. The included articles directly observed a clinical adverse effect or effects on drug plasma concentrations from the concomitant use of the two listed drugs in each pDDI. These articles were classified as controlled studies (e.g., randomized controlled trials, clinical trials, or observational studies) or uncontrolled studies (case reports). A total of 124 studies with 2716 patients were included in this review. Commonly evaluated adverse effects related to the studied pDDIs included decreased effectiveness, central nervous system depression, neurotoxicity, QT-interval prolongation, and serotonin syndrome. Among the 58 pDDIs, 18 (31%) were not supported by any primary studies. Among the remaining 35 pDDIs supported by studies on clinical adverse effects, only 14 (40%) included evidence from controlled study designs. Only 7 (12.1%) of the 58 pDDIs had evidence from studies with a combined sample size of more than 100 patients. This literature review highlights the poor quality of evidence supporting major or contraindicated psychotropic DDI warnings. Most DDIs lacked support from controlled studies that evaluated clinically significant adverse effects, leaving uncertainty about the clinical relevance of the warning. More postmarketing studies are needed to evaluate the safety of psychotropic combination therapy.

Development and Validation of an Administrative Claims-based Measure for All-cause 30-day Risk-standardized Readmissions After Discharge From Inpatient Psychiatric Facilities.

OBJECTIVE: The objective of this study was to develop and test a measure that estimates unplanned, 30-day, all-cause risk-standardized readmission rates (RSRRs) after inpatient psychiatric facility (IPF) discharge. PARTICIPANTS: We established a retrospective cohort of adults with a principal diagnosis of psychiatric illness or dementia discharged from IPFs to nonacute care settings, using 2012-2013 Medicare fee-for-service claims data. MEASURES: All-cause unplanned readmissions within 3-30 days post-IPF discharge were assessed by constructing then validating a parsimonious logistic regression model of 56 risk factors (selected via empirical data, systematic literature review, clinical expert opinion) for readmission using bootstrapping. RSRRs were calculated from the ratio of predicted versus expected readmission rates for each IPF using hierarchical regression. Measure reliability and validity were assessed via multiple strategies. RESULTS: The measure development cohort included 716,174 admissions to 1679 IPFs and 149,475 (20.9%) readmissions. Most readmissions (>80%) had principal diagnoses of mood, schizoaffective or substance use disorders, delirium/dementia, infections or drug/substance poisoning. Facility RSRRs ranged from 11.0% to 35.4%. The risk adjustment model showed good calibration and moderate discrimination similar to other readmission risk models (c statistic 0.66). Sensitivity analyses solidified the risk modeling approach. The intraclass correlation coefficient of estimated IPF RSRRs was 0.78, indicating good reliability. The measure identified 8.3% of hospitals as having better and 13.4% as having worse RSRRs than the national readmission rate. CONCLUSIONS: The measure provides an assessment of facility-level quality and insight into risk factors useful for informing preventive interventions. The measure will be included in the Centers for Medicare and Medicaid Services (CMS) Inpatient Psychiatric Quality Reporting program in 2019.

Psychometric Properties of the Vanderbilt ADHD Diagnostic Rating Scale Completed by Juvenile Corrections Staff.

Objective: This research tests the psychometric performance of the Vanderbilt ADHD Diagnostic Teacher Rating Scale (VADTRS) completed by juvenile corrections (JC) staff. Method: With institutional review board (IRB) approval and appropriate consents/assents, data were collected from case managers (n = 18), teachers (n = 9), youth (n = 261), and an administrative database. Separate psychometric analyses were conducted for case managers and teachers. Results: For both respondent groups, 2-week retest reliability and internal consistency were high for all four VADTRS subscales, and confirmatory factor analysis suggested fit with previously reported VADTRS subscale structure. Significant correlations of VADTRS with respective Revised Behavior Problem Checklist subscale scores indicated good concurrent validity. Discriminative validity was strong for ADHD, but not for conduct subscales. Interrater agreement was poor, similar as reported in other settings. Conclusion: Acceptable VADTRS psychometric performance among two JC staff groups supports guideline-consistent practice of obtaining standardized rating scale information from JC staff to enhance the quality of ADHD treatment.

Commercial mindfulness aid does not aid short-term stress reduction compared to unassisted relaxation.

Increased public interest in mindfulness has generated a burgeoning market in new consumer technologies. Two exploratory studies examined effects of InteraXon's "Muse" electroencephalography (EEG)-based neurofeedback device and mobile application on mindfulness-based relaxation activities. Psychophysiological outcomes (heart rate variability (HRV), electro-dermal activity (EDA), saliva amylase activity (sAA) and Muse application EEG "calm percent") were collected for two 7-minute conditions: Muse-assisted relaxation exercise (MARE), and unassisted relaxation exercise (URE). In the first study, participants (n = 99) performed both conditions in a randomized sequential design. A follow-up study used a randomized parallel condition (n = 44) to test for differences in HRV effects between the two conditions and extended follow-up observation. Generalized estimating equation models demonstrated a moderate increase in HRV following relaxation exercises, with no observable difference between MARE and URE conditions. Both MARE and URE conditions produced equally effective short-term increases in heart rate variability, without additional benefit from neurofeedback.

Disruptive Behaviors across Different Disorders: Evaluation of a Clinical Sample Using the Eyberg Child Behavior Inventory.

OBJECTIVE: The study reports the prevalence of disruptive behaviors in a help-seeking sample of young children across a diverse range of clinical diagnoses (based on ICD-10). METHOD: The Eyberg Child Behavior Inventory (ECBI), a parent rating scale of disruptive behaviors, was completed on 310 children (2-11 years) at three child and adolescent psychiatry clinics in three German states (Bavaria, Hesse, Lower Saxony); the majority of children were outpatients. RESULTS: Mean intensity scores of disruptive behaviors differed significantly by diagnostic group, with the lowest ratings within a community sample, and increasingly higher scores in children with a diagnosis from the internalizing spectrum, those with pervasive developmental disorders, and finally, those with externalizing disorders (e. g. hyperkinetic disorder, conduct disorders). Seventy percent of the clinical sample, compared to only 17 % of the community sample, exceeded the normative cut-off score of 111, indicating that disruptive behaviors are common in young German children seeking help for different mental health problems. CONCLUSIONS: These findings support the Research Domain Criteria approach by showing that disruptive behaviors cross our current diagnostic labels and may need to be assessed and conceptualized in treatment planning, even in children without a primary diagnosis from the externalizing spectrum.

Psychotropic Treatment Pattern in Medicaid Pediatric Patients With Concomitant ADHD and ODD/CD.

OBJECTIVE: To describe psychotropic treatment pattern and evaluate the association of socio-demographic factors and psychotropic combination therapy in children with ADHD and oppositional defiant disorder/conduct disorder (ODD/CD). METHOD: This is a cross-sectional drug utilization study based on Medicaid fee-for-service programs in 26 U.S. states (1999-2006). Children aged 4 to 18 with concomitant ADHD and ODD/CD were included. We calculated the prevalence of psychotropic drugs and used logistic regression to evaluate the role of socio-demographic factors in psychotropic combination therapy. RESULTS: We identified 121,740 children with ADHD and ODD/CD (140,777 person-years). The period prevalence of "no psychotropic therapy," psychotropic monotherapy, and psychotropic dual therapy was 38.1%, 44.7%, and 9.0%, respectively. The most common drug class was stimulants. Whites, males, and children in foster care were more likely to use psychotropic combination therapy. State-level variation was observed. CONCLUSION: "No psychotropic therapy" and stimulants dominate treatment choices in children with ADHD and ODD/CD. Socio-demographic characteristics are associated with combination psychotropic therapy.

Prevalence, Time Trends, and Utilization Patterns of Psychotropic Polypharmacy Among Pediatric Medicaid Beneficiaries, 1999-2010.

OBJECTIVES: This study estimated the prevalence, time trends, and state-level variation of same- and multiclass psychotropic polypharmacy among youths in Medicaid fee-for-service plans. METHODS: Using pharmacy records from 29 Medicaid states from 1999 to 2010, the authors constructed ten two-year cohorts of beneficiaries between ages 0 and 17 years who received at least one psychotropic to treat a mental disorder. Polypharmacy was defined as any period in which dispensed days' supply of psychotropics overlapped for more than 45 days. Same- and multiclass psychotropic polypharmacy prevalence was stratified by age and state. RESULTS: A total of 692,485 children were included across each two-year cohort. The prevalence of any-class and multiclass psychotropic polypharmacy grew steadily, from 21.2% and 18.8% in 1999-2000 to 27.3% and 24.4% in 2009-2010, respectively. The prevalence increased with older age, with highest estimates for late adolescents. For same-class psychotropic polypharmacy, a constant upward trend was noted over time, except for antidepressants. Polypharmacy increased over the decade for central nervous system stimulants, from .1% to .6%, and for alpha-agonists, from .1% to .4%. Heterogeneous prevalences of psychotropic polypharmacy were noted across states, ranging from 6.9% to 48.8% for any-class psychotropic polypharmacy, from .4% to 6.4% for same-class antidepressant polypharmacy, and from .1% to 4.6% for antipsychotics. CONCLUSIONS: The study found an overall increasing trend of psychotropic polypharmacy coupled with significant variation across the examined states. A more granular assessment that considers patient characteristics and local contextual factors is warranted.