Factors Associated with Management of Teen Aggression: Child Psychiatric Clinical Decision Making

Abstract

Objective:

This study explores whether patient-specific and clinician-specific factors are associated with child psychiatrists' use of second generation antipsychotics (SGAs) in the management of aggression in children with attention-deficit/hyperactivity disorder (ADHD). The patient-specific factors included patient's race, caregiver status, and patient engagement in psychotherapy.

Methods:

Child psychiatrists attending an annual conference (n = 156) were asked to complete an anonymous questionnaire on clinical decision making. Each participant was randomized to one of eight vignettes on a physically aggressive male teenager with methylphenidate-responsive ADHD. Patient race, caregiving status, and patient engagement in psychotherapy were systematically varied. Respondents rated how likely they were to prescribe an SGA and whether they would adjust the patient's current medication.

Results:

Seventy-five percent of participants (n = 117) were uncomfortable with adding an SGA, and 61% (n = 95) were likely to make medication adjustments to the current stimulant. None of the patient-specific factors were related to management recommendations. However, inpatient psychiatrists compared with non-inpatient psychiatrists reported a higher likelihood of using antipsychotics (OR = 2.40, 95% CI [1.181, 4.879], p = 0.016). Midwestern psychiatrists compared with those from other regions also reported a higher likelihood of using antipsychotics (OR = 3.07, 95% CI [1.376, 6.857], p = 0.005). Academic psychiatrists compared with nonacademics were less likely to endorse making adjustments to the current medication regimen (OR = 0.49, 95% CI [0.860, 0.274], p = 0.013).

Conclusions:

When presented with a hypothetical case, the vast majority of child psychiatrists surveyed advised that additional information was needed before adding an SGA. Many felt the need for more psychosocial information and greater clarity of possible comorbid diagnoses.

Introduction

Over the past two decades there has been a trend of increased use of second-generation antipsychotics (SGAs) to treat mental health problems in youth (Zito et al. 2003; Cooper et al. 2004; Olfson et al. 2006; Verdoux 2010). Between 2000 and 2002, an estimated 92% of all antipsychotic medications prescribed to children in outpatient practices were SGAs (Olfson et al. 2006). The rising use of these medications, both on-label and off-label, has generated concern because of a dearth of head-to-head studies on their relative efficacy and their metabolic side effects (Seida et al. 2012). There has been growing recognition of the risks of weight gain, hyperlipidemia, hyperglycemia, hyperprolactinemia, and diabetes mellitus, which may be more profound in youth than in adults (De Hert et al. 2011). Children are potentially more vulnerable to these side effects during long-term use because of the significant physiological (Crystal et al. 2009) and emotional changes that they undergo during childhood and adolescence.

Although the United States Food and Drug Administration (FDA) approved risperidone in 2006 and aripiprazole in 2009 for treatment of irritability in autistic children, these medications and other SGAs are being used frequently for disruptive behavior disorders (DBDs), attention-deficit/hyperactivity disorder (ADHD), and mood disorders (Cooper et al. 2004; Olfson et al. 2006). This pattern, especially among vulnerable youth (e.g., those in foster care or on Medicaid) has raised concerns among clinicians, lawmakers, and the general population. Efforts to address this complex issue are demonstrated by revised clinical practice parameters, media coverage, and government guidelines (Pappadopulos et al. 2003; Canadian Agency for Drugs and Technologies in Health 2011; United States House of Representatives 2011).

Several general factors contributing to this issue include: Fragmented mental health systems; limited access to coordinated, effective psychosocial treatment; influence from pharmaceutical companies (Harris and Roberts 2007), differential reimbursement from Medicaid (Seida et al. 2012), and a reactive professional climate. One should also consider biological vulnerability, parents' roles and expectations, and psychosocial stressors specific to the individual child (Alavi et al. 2012). Many child psychiatrists are under increasing pressure from insurance companies and families to find quick solutions to complex psychological and behavioral problems in resource-limited environments (Wilk et al. 2005).

Off-label use of psychiatric medications in children is actually common practice (Rodday et al. 2014), in part because <50% of all medications have pediatric labeling from the FDA (Frattarelli et al. 2014). Large scale, standardized clinical trials are frequently unavailable: therefore, pediatric providers must rely on case series, expert opinion, or evidence from a different population to guide clinical decision making (Frattarelli et al. 2014). Recent legislature has incentivized drug companies to test the efficacy and safety of medications in children with large randomized placebo-controlled trials (Medicine Io 2012). Despite these efforts, rigorous standardized trials for adolescents are lacking, particularly for management of aggression and other nonpsychotic disorders (Pappadopulos et al. 2003; Schur et al. 2003).

In addition, prescription of more than one psychotropic medication has become common practice and may be justifiable when medications offer different mechanisms of actions to target co-occurring symptoms (Gadow et al. 2014). Comorbid conditions are common in children with psychiatric disorders, and the boundaries between the disorders are often inexact.

One study has attempted to look at stimulant augmentation with an SGA in aggressive youth. This randomized placebo-controlled study showed modest improvement in reactive antisocial behavior and moderate improvement in disruptive behaviors in physically aggressive youth with ADHD and a DBD whose stimulant regimen was augmented with risperidone (Aman et al. 2014). The children were on both methylphenidate and risperidone for 6 weeks. Gastrointestinal discomfort, increases in prolactin levels, and weight gain were statistically significant side effects found in the combined treatment arm. An open label trial by Gadow et al. showed variable (small to moderate) effect sizes for reducing ADHD and oppositional defiant disorder (ODD) symptoms and peer aggression when risperidone was added to a stimulant (Gadow et al. 2014). Clinical improvement was context dependent.

Examining child psychiatrists' attitudes and factors involved in clinical decision making is helpful for understanding current prescribing practices and to inform future research for the purpose of establishing standard of care guidelines. Clinical decision making is a growing area of research, because medical management of patients is subject to nonmedical influences (Feldman et al. 1997; McKinlay et al. 2002; Dumesnil et al. 2012).

Although prescription practices and attitudes towards off label use vary among child psychiatrists in different clinical settings (Goodwin et al. 2001; Rodday et al. 2014), virtually no research has been conducted to examine nonmedical factors influencing clinical decision making. Factorial survey design allows examination of two to three variables in a systematic way by a large, random sample of physicians. There have been a few studies employing this technique to examine clinical decision making in management of psychiatric disorders in adults (Epstein et al. 2008; Dumesnil et al. 2012; Hutschemaekers et al. 2014).

To the best of our knowledge, there are no studies in which child psychiatric clinical decision making has been examined. The goal of the present study was to assess child psychiatrists' treatment recommendations for a young adolescent presenting with aggression. We anticipated that the child's race, caregiving context (e.g., living with biological or foster parent), and whether the patient was in psychotherapy would influence psychiatrists' recommendations. Race and caregiving status were chosen because extensive epidemiological research has examined SGA use in foster care youth according to race. Leslie et al. showed a strong association between caregiver status and medication use among European American children (Leslie et al. 2010). A recent multistate study of Medicaid enrollees demonstrated that children of European descent were more likely than African, Hispanic, and Asian American children to receive both antipsychotic drugs and psychiatric services (Cataife et al. 2015).

Psychotherapy was chosen as a third factor because practice guidelines for the field recommend psychotherapy and/or behavioral intervention for management of ADHD with aggression (Pliszka et al. 2006).

We also expected to see that psychiatrists practicing in academic environments, in comparison with private practice, would be less likely to recommend an antipsychotic for aggression because they are more able to provide combined psychotherapy and medication management to Medicaid populations through their training programs. We also expected that psychiatrists working in inpatient settings would be more comfortable prescribing antipsychotics for management of aggression in an outpatient setting. This prediction was guided by results from a recent study on child psychiatrists' prescription practices by Rodday et al. (2014). We expected that there would be regional differences in prescribing practices (Rawal et al. 2004), but had no predictions about which regions would be more conservative, because no recent child studies were available. We had no further expectations about which physician characteristics would be associated with conservative versus aggressive medication management. Lastly, based on pharmacoepidemiological studies, we anticipated that the European American foster child would be more likely to be recommended a concomitant atypical antipsychotic (Crystal et al. 2009; Zito et al. 2008; Leslie et al. 2010; Dosreis et al. 2011).

Methods

Sampling

Permission was obtained by the assistant director of the meeting to survey child psychiatrists in the lobby of the conference hotel. This study was reviewed by University of Chicago Institutional Review Board, who granted exempt status to the project because of the voluntary, anonymous nature of the study, posing minimal risk to participants. There were ∼3500 attendees, of which 2200 were child psychiatrists. One individual refused to respond to the survey after reading the vignette. Responses were obtained from 156 child psychiatrists who spent ∼5–10 minutes responding to questions from a paper survey. Survey responses were kept anonymous and confidential. Participants were randomized to receive a coffee card or a snack.

Procedure and questionnaire

Clinicians were informed that they were participating in a study of clinical decision making. They were asked to provide data on gender, race, ethnicity, age, state in which they practice, years of child psychiatry practice, and whether they provided psychotherapy. They were also asked to select descriptive words from a list that best characterized their type of practice (private, community mental health, academic, inpatient, outpatient, urban, suburban, or rural). A copy of the survey is included in Appendix A.

The study was based on factorial survey design described in the clinical decision-making literature (Farrell and Lewis 1990; Morrissey et al. 1995). The following factors were chosen: Race (African American vs. European American), caregiver (biological parent vs. foster parent), and whether or not the child was in psychotherapy. Therefore, two (Cooper et al. 2004) yielded eight clinical vignettes, which participants were randomly assigned to read. Based on sample-size calculations from previous studies, a minimum of 32 subjects (or four replications of the eight vignettes) was expected for the study to achieve 80% power to detect 15% difference in recommendation decisions at a 0.05 significance level (Schulman et al. 1999).

Clinical vignette

The patient is a 13-year-old [white/black] male, who is brought in by his [biological/foster] mother for management of his disruptive behavior. You have been seeing him for the past 3 months. He has well-established ADHD responsive to methylphenidate. He has previously been tried on amphetamine mixed salts.

He has shown improvement in his academic performance and organization. However, his mother reports that he continues to act “out of control.” His teachers describe him as being disruptive in class since he sometimes gets into arguments with other students. He has become more argumentative about completing his homework. Two months ago he became furious with his mother after she confiscated his video game console. He responded by intentionally tearing up his younger sister's homework.

This month he has been increasingly more destructive, breaking windows, and throwing chairs. For the first time last week, he tried to push his mother. His mother tells you in private that she has become fearful for her own safety. He [is/is not] in weekly psychotherapy.

After reading the clinical vignette, participants were asked two questions about management of this case: 1) How likely are you to recommend starting a low dose atypical antipsychotic? and 2) How likely are you to recommend changing the dose of methylphenidate or switching to a different ADHD medication? Responses were made using a six point likert scale ranging from (1) very unlikely to (6) very likely. Participants were provided an opportunity to write additional comments.

Statistical analysis

The Likert scale responses were treated as ordinal variables using a proportional odds model. This model is useful for analyzing survey responses that are highly nonnormal but have an intrinsic ordering (Gemeroff 2005). One benefit of the proportional odds model is that the odds ratio for each independent variable is constant across all possible approaches to categorizing the dependent variable (antipsychotic vs. conservative management), and are, therefore, interpreted as the odds of being higher or lower on the dependent variable across the entire range of outcomes (Gemeroff 2005). All factors demonstrating a statistically significant relationship with cumulative likelihood scores at the p < 0.10 level were used in the final multivariate models. Two multivariate models were created: One for the likelihood of adding an SGA and one for the likelihood of adjusting the current stimulant medication. The final SGA model contained two variables: Inpatient psychiatrist and Midwestern psychiatrist. The final model accounting for medication adjustment contained the caregiver variable and the academic clinician variable.

Results

Sample characteristics

The 156 participants ranged in age from 26 to 78 years (mean 43.5, SD 13.8). Approximately 51% (n = 81) of the sample was female, and 44% (n = 69) were male, with 8 participants missing gender data. Two thirds (60.3%, n = 94) of participants identified themselves as European American, ∼10% (n = 15) identified as African American, 25% (n = 40) identified as Asian American, and 3.8% (n = 6) identified as multiracial. Race was missing for one participant. Sixty percent (n = 93) of participants identified as non-Hispanic, and 9% (n = 14) identified as Hispanic, with 20.5% (n = 32) identifying as “other.” Ethnicity was missing for 17 participants.

Fellows and early career child psychiatrists made up a significant proportion of the sample, with 46% (n = 71) being ≤35 years old. Number of years of psychiatric practice ranged from <1 year to 61 years (mean 10.5, SD 12.3), with 51% (n = 79) reporting <5 years' experience. Because physician age and years in practice were highly correlated (R² = 0.76) only years of practice was kept in the final model, as missing data for this variable were minimal.

More participants practiced in the Northeast (37.8% n = 59), relative to the West (12.8%, n = 20), Midwest (18.6% n = 29), and South (29.5% n = 46). Of the 146 participants who answered the question about providing psychotherapy, 75.6% (n = 118) were providers of psychotherapy. Approximately half of all participants reported working in an academic practice. Roughly 30% of the sample practiced in an urban setting, and 40% practiced in an outpatient environment. Participants could select all descriptions that applied.

Analysis of antipsychotic question

Seventy-five percent (n = 117) of participants responded that they were unlikely to add an antipsychotic. None of the patient-specific variables within the clinical vignette were significantly associated with participants' responses to the question about antipsychotic treatment. Favoring use of antipsychotic medication was not associated with clinician years of experience or age. However, two physician variables were significantly associated with use of SGA medication: Midwest location (OR 3.19, 95% CI [1.47, 7.45], p = 0.004) and practicing in an inpatient setting (OR 2.71, 95% CI [1.35, 5.44], p = 0.005). Pearson residual plots for the cumulative probability on the logit scale were used to identify possible outliers, of which there was one, who selected “extremely likely” to add an antipsychotic. Model fit was satisfactory after removing the outlier.

Table 1 contains the results of the final multivariate models. Child psychiatrists from the Midwest had a higher odds of endorsing addition of an antipsychotic to the stimulant (OR = 3.19, p = 0.005) than those from the West. When the model was run with combining all other regions as the comparison group, the Midwestern psychiatrists continued to demonstrate a greater odds of selecting an antipsychotic than those from other regions (OR = 3.07, CI [1.376, 6.857], p = 0.005). Inpatient clinicians also had a higher odds of adding an antipsychotic (OR = 2.40, 95% CI [1.181, 4.879], p = 0.016) than non-inpatient clinicians.

Table 1.

Multivariate Proportional Odds Analysis

Relationship of patient-specific and clinician-specific factors with likelihood of adding an SGA ^a
Independent variables	OR	95% CI	p value
Inpatient psychiatrist (n = 33)	2.40	1.181, 4.879	0.016
Midwestern psychiatrist (n = 29)	3.07	1.376, 6.857	0.005

Relationship of patient-specific and clinician-specific factors with likelihood of adjusting current stimulant
Independent variables	OR	95% CI	p value
Academic psychiatrist (n = 78)	0.49	0.860, 0.274	0.013
Foster child (n = 79)	0.60	0.339, 1.056	0.076

No patient-specific factors were significantly associated with likelihood of adding a second generation antipsychotic (SGA).

Analysis of medication adjustment question

Approximately 60% (n = 95) of participants reported that they were likely to make medication adjustments to the current stimulant. Foster care status was associated with not recommending adjustment of the stimulant (OR 0.62, p = 0.097) compared with for those patients with biological caregivers. Academic psychiatrists also were less likely to endorse making adjustments the current stimulant regimen (OR 0.50, p = 0.016), than those in all other practice settings. The final model was fitted with both the caregiver variable and the academic clinician variable. The association between academic clinicians and likelihood of stimulant medication adjustment remained significant (OR 0.49, 95% CI [0.860, 0.274], p = 0.013). However, the association between youth being in foster care and adjustment of stimulant medication did not reach significance at p < 0.05.

Forty-eight percent (n = 75) of participants wrote comments after answering questions about the vignette. The main themes that emerged from participant comments included requests for more background information as well as the desire to address the behavioral problem with parent training, family therapy, and individual therapy. Some expressed a preference for using a different class of medication with fewer side effects (e.g., clonidine). Twenty-five percent of clinicians (n = 39) felt the need for additional information, including urine toxicology results, collateral information from the teacher, and more background about psychosocial stressors.

Discussion

The main findings suggest that there are several clinician-specific factors that may influence clinical decision making, which have implications for training programs, regional and state mental health systems, and professional practice parameters.

The association between psychiatrists being from the Midwest and greater likelihood of antipsychotic use suggests regional variation in prescription practices. In 2004, Rawal et al. showed that physicians practicing in residential units in the Midwest were less likely to prescribe antipsychotics compared to residential units in three other states in the United States (Rawal et al. 2004). Residential treatment facility trends may not correlate with outpatient trends, and there may be changes in prescription patterns over the past 10 years since the article was published. Illinois is somewhat unique in that a third party (clinician) oversees all of the psychotropic prescriptions for child Medicaid patients. Approval must be obtained from the Illinois Medicaid agency before prescribing any psychotropic medications, including antipsychotics. Given these restrictions in Illinois, it is surprising that Midwestern psychiatrists were more likely to prescribe antipsychotics. Perhaps the clinicians surveyed from the Midwest tend to see different patient populations than those served by Medicare, or the review process makes clinicians feel that there are more safeguards for prescribing.

As predicted, those child psychiatrists working in inpatient settings were more likely to prescribe antipsychotics for aggression. Rodday et al. showed that inpatient and residential clinicians were more likely to use SGAs for off-label management of ADHD, ODD, conduct disorder, and nonbipolar mood disorders (Rodday et al. 2014). Psychiatrists in these settings treat children with greater severity of illness compared with their outpatient colleagues, and also are often under time pressure to control symptoms quickly. There is also more support for close safety monitoring during medication trials in these settings.

The finding that psychiatrists practicing in academic settings are less likely to make adjustments to the stimulant medication may reflect greater access to psychotherapists, including trainees who may be less dependent on third party reimbursement. These programs may have more opportunities to provide behavioral interventions, parent training, and family therapy to youth with externalizing disorders than clinicians in private practice would have. Academic institutions often have more support staff (e.g., psychologists, social workers, case managers, psychiatric nurses) than individual mental health providers.

Race, caregiver status (foster vs. biological parent), and psychotherapy engagement were not significantly associated with treatment recommendations for outpatient management of aggression. Although none of the patient-specific factors were associated with medication recommendations, it is possible that characteristics such as race and sex have greater impact on clinical decision making when presented in a video vignette format, which was demonstrated in a seminal study by Schulman et al. with regard to cardiac catheterization (Schulman et al. 1999).

There is evidence that clinicians carry stereotypes that unconsciously influence their interpretation of behaviors and symptoms, and their clinical decisions (Burgess et al. 2007). Retrospective studies suggest that race influences psychiatric diagnosis of hospitalized adolescents (DelBello et al. 2001). Future research on clinical decision making would ideally provide a video-based vignette to decrease the amount of cognitive processing that occurs while participants develop a formulation and recommendation. Video vignettes would also provide opportunity to include more details about the case with factors such as race, insurance, gender, and diagnosis varied systematically.

Limitations

There were several limitations to this study. The convenience sample of participants from the conference is not representative of the child psychiatric community at large. The survey's scope was limited to clinician recommendations at one time point in treatment. It forced clinicians to make a decision based on limited information, which seemed to provoke strong reaction from 48% (n = 75) of participants who wrote comments on alternative means of managing the case. Although alpha agonists were not explicitly provided as an option, clinicians were asked in the second question whether they would consider switching to a “different ADHD medication.” Examining other potential confounders would help clarify the findings of this study, such as insurance status, clinician reimbursement, and whether early career psychiatrists, who were well represented, are more likely to be in academic practice. Besides including a more refined clinical vignette, future studies would allow for sequential answer choices at different time points in treatment and include type of antipsychotic, other classes of medications, and specific options for psychotherapies.

Conclusions

To our knowledge, this is the first study of its kind examining child psychiatrists' decision making. The management of comorbid aggression in outpatient practice is challenging, and often complicated by deficits in other areas of functioning. The growing use of SGAs to manage aggression has raised concerns about the appropriateness of their off-label use in children given their associated metabolic and extrapyramidal side effects. Given the paucity of literature examining clinical decision making in child psychiatrists, these findings merit further investigation. Understanding clinician behaviors and attitudes can help identify influences on prescription patterns and promote revision of future practice parameters.

Footnotes

Clinical Significance

Patterns in clinical decision-making impact patient care. Our findings suggest that clinician-specific factors may influence clinical decision making and should encourage further discussion and development of evidence-based practice guidelines.

Disclosures

No competing financial interests exist.

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