Management of Children and Youth with Neurodevelopmental Disorders (NDDs) in Community Settings Prior to Referral to a Tertiary Psychopharmacology Clinic

Background:

The use of second-generation antipsychotic (SGA) medications to alleviate symptoms of irritability and aggression in children with autism spectrum disorder (ASD) has increased considerably in the past decade. Although efficacious, SGAs can be associated with significant cardiometabolic and neurologic risks. Given the increased susceptibility of the paediatric population to these adverse effects (AEs), the Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA) developed a set of guidelines in 2011 to provide physicians with clinical and laboratory testing recommendations for SGA monitoring. In this study, we undertake the first evaluation of CAMESA Guideline uptake amongst physicians to ensure that children with neurodevelopment disorders (NDDs) taking SGAs are receiving the current standard of care.

Objectives:

Primary: To determine how the introduction of the CAMESA Guidelines has impacted the frequency of clinical and laboratory investigations to monitor for AEs in children/youth with NDDs treated with SGAs.

Secondary:

1. Describe the sample of children/youth referred to a tertiary psychopharmacology clinic;
2. Determine rates of SGA prescription in the community and duration of treatment.

Methods:

A retrospective chart review was undertaken to compare rates of clinical monitoring of children/youth with NDDs treated with SGAs and referred to the Holland Bloorview psychopharmacology clinic before (2008-2011) and after (2013-2016) publication of the CAMESA Guidelines. Children on SGAs were divided into three categories based on reports of clinical monitoring: (1) Any investigations complete, (2) No investigations complete, and (3) Not specified. A Fischer’s exact test was used to detect a statistically significant change in monitoring rates between the two time periods. Thoroughness of monitoring by CAMESA standards was also assessed. Descriptive statistics were used to address secondary objectives.

Results:

A total of 285 charts were reviewed (n=135 pre-CAMESA, n=150 post-CAMESA). The average age of children referred to the clinic was 10.4 years (range 2-18), with ASD as the most prevalent diagnosis amongst the population. The most common reasons for referral were aggression and hyperactivity/impulsivity. Forty-one percent of referred children were started on an SGA before arriving at the clinic, and median treatment duration was 17 months at the time of the first clinic visit. There is a nonsignificant difference (p=0.62) in the proportion of children on SGAs (n=48 pre-CAMESA, n=70 post-CAMESA) monitored for AEs before and after publication of the guidelines. Monitoring rates pre- and post-CAMESA were 35% and 44%, respectively. Of the children monitored, only 33% in the pre-CAMESA period and 63% in the post-CAMESA period underwent comprehensive investigations. This again represents a nonsignificant difference (p=0.11) in thoroughness of monitoring between the two time periods.

Conclusions:

We aim to provide novel insight into SGA monitoring practices and emphasize the importance of health risk minimization when prescribing these medications. Given that SGA monitoring rates did not significantly improve after CAMESA guideline publication, and that less than half of children on SGAs underwent monitoring, we have identified a gap in standard of care provision. There is a need to undertake future studies to identify barriers to guideline uptake and implement appropriate interventions to address them.