Anjali Jain

Psychotropic Medication Use and Polypharmacy in Children With Autism Spectrum Disorders

OBJECTIVE: The objectives of this study were to examine rates and predictors of psychotropic use and multiclass polypharmacy among commercially insured children with autism spectrum disorders (ASD). METHODS: This retrospective observational study used administrative medical and pharmacy claims data linked with health plan enrollment and sociodemographic information from 2001 to 2009. Children with ASD were identified by using a validated ASD case algorithm. Psychotropic polypharmacy was defined as concurrent medication fills across ≥2 classes for at least 30 days. Multinomial logistic regression was used to model 5 categories of psychotropic use and multiclass polypharmacy. RESULTS: Among 33 565 children with ASD, 64% had a filled prescription for at least 1 psychotropic medication, 35% had evidence of psychotropic polypharmacy (≥2 classes), and 15% used medications from ≥3 classes concurrently. Among children with polypharmacy, the median length of polypharmacy was 346 days. Older children, those who had a psychiatrist visit, and those with evidence of co-occurring conditions (seizures, attention-deficit disorders, anxiety, bipolar disorder, or depression) had higher odds of psychotropic use and/or polypharmacy. CONCLUSIONS: Despite minimal evidence of the effectiveness or appropriateness of multidrug treatment of ASD, psychotropic medications are commonly used, singly and in combination, for ASD and its co-occurring conditions. Our results indicate the need to develop standards of care around the prescription of psychotropic medications to children with ASD.

Autism Occurrence by MMR Vaccine Status Among US Children With Older Siblings With and Without Autism

IMPORTANCE Despite research showing no link between the measles-mumps-rubella (MMR) vaccine and autism spectrum disorders (ASD), beliefs that the vaccine causes autism persist, leading to lower vaccination levels. Parents who already have a child with ASD may be especially wary of vaccinations. OBJECTIVE To report ASD occurrence by MMR vaccine status in a large sample of US children who have older siblings with and without ASD. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study using an administrative claims database associated with a large commercial health plan. Participants included children continuously enrolled in the health plan from birth to at least 5 years of age during 2001-2012 who also had an older sibling continuously enrolled for at least 6 months between 1997 and 2012. EXPOSURES MMR vaccine receipt (0, 1, 2 doses) between birth and 5 years of age. MAIN OUTCOMES AND MEASURES ASD status defined as 2 claims with a diagnosis code in any position for autistic disorder or other specified pervasive developmental disorder (PDD) including Asperger syndrome, or unspecified PDD (International Classification of Diseases, Ninth Revision, Clinical Modification 299.0x, 299.8x, 299.9x). RESULTS Of 95,727 children with older siblings, 994 (1.04%) were diagnosed with ASD and 1929 (2.01%) had an older sibling with ASD. Of those with older siblings with ASD, 134 (6.9%) had ASD, vs 860 (0.9%) children with unaffected siblings (P < .001). MMR vaccination rates (≥1 dose) were 84% (n = 78,564) at age 2 years and 92% (n = 86,063) at age 5 years for children with unaffected older siblings, vs 73% (n = 1409) at age 2 years and 86% (n = 1660) at age 5 years for children with affected siblings. MMR vaccine receipt was not associated with an increased risk of ASD at any age. For children with older siblings with ASD, at age 2, the adjusted relative risk (RR) of ASD for 1 dose of MMR vaccine vs no vaccine was 0.76 (95% CI, 0.49-1.18; P = .22), and at age 5, the RR of ASD for 2 doses compared with no vaccine was 0.56 (95% CI, 0.31-1.01; P = .052). For children whose older siblings did not have ASD, at age 2, the adjusted RR of ASD for 1 dose was 0.91 (95% CI, 0.67-1.20; P = .50) and at age 5, the RR of ASD for 2 doses was 1.12 (95% CI, 0.78-1.59; P = .55). CONCLUSIONS AND RELEVANCE In this large sample of privately insured children with older siblings, receipt of the MMR vaccine was not associated with increased risk of ASD, regardless of whether older siblings had ASD. These findings indicate no harmful association between MMR vaccine receipt and ASD even among children already at higher risk for ASD.

Does a claims diagnosis of autism mean a true case

The purpose of this study was to validate autism spectrum disorder cases identified through claims-based case identification algorithms against a clinical review of medical charts. Charts were reviewed for 432 children who fell into one of the three following groups: (a) more than or equal to two claims with an autism spectrum disorder diagnosis code (n = 182), (b) one claim with an autism spectrum disorder diagnosis code (n = 190), and (c) those who had no claims for autism spectrum disorder but had claims for other developmental or neurological conditions (n = 60). The algorithm-based diagnoses were compared with documented autism spectrum disorders in the medical charts. The algorithm requiring more than or equal to two claims for autism spectrum disorder generated a positive predictive value of 87.4%, which suggests that such an algorithm is a valid means to identify true autism spectrum disorder cases in claims data.

Fighting obesity: Evidence of effectiveness will be needed to sustain policies

Obesity is no longer just an American problem. The UK House of Commons Health Committee issued its report on obesity on 27 May 2004 predicting that obesity would soon overtake smoking as the leading health problem in the United Kingdom.1 Throughout Europe, obesity has increased 10-50% within the past decade and by as much as 75% in parts of the developing world.2 Worldwide over a billion adults and children are overweight,3 and some experts have predicted that the current generation of children are likely to have shorter life expectancies than their parents because of obesity.1 Experts agree that the causes of the obesity epidemic are environmental, related to living in surroundings that allow easy access to food and little need for exercise. To date most approaches to obesity have focused on changing the behaviour of individuals—on diet and exercise—and cumulatively these have had little or no impact on the increasing prevalence of obesity. The report by the health committee is the first to describe a comprehensive and integrated strategy that emphasises the environmental contributors to the obesity problem. Unlike policies in the United States, which promote individual rather than state responsibility for the obesity problem, the strategy in the United Kingdom specifically states that the solution does not lie with the individual or doctors office. The United Kingdom report recommends measures including the simpler labelling of food with red, yellow, and green symbols (categorising healthfulness) and banning vending machines and school sponsorships by companies associated with unhealthy foods, and better access to programmes to treat obesity. The report was critical of the British government, essentially describing current initiatives to tackle obesity as much talk but little action. Both this report by the health committee and the World Health Organizations recent global strategy on diet, physical activity, and health have implicated the marketing of junk foods as an important cause of obesity, but they propose different solutions. WHO called for immediate bans on the advertising of unhealthy foods to children and restrictions on sugar content. The recommendations were criticised for not being evidence based allowing officials of the food industry to stall the plan. A remarkable feature of the health committees report is its call for the voluntary participation of the food industry in anti-obesity initiatives. The plan represents a willingness of the government to take corporate executives at their word, at least temporarily, to believe they are interested in the health of consumers. Members of the health committee state rightly that an approach using incentives instead of legislated restrictions may produce results faster and yield more creative solutions. The reports recommendations are necessary and sensible but are not based on evidence of effectiveness.4 Few strategies for obesity have been proved to work. The only interventions that are well supported by research are surgery for the morbidly obese; drugs; and multicomponent weight loss programmes consisting of diet, exercise, and behaviour therapy.5 These studies have been done in clinical settings with adults and, with the exception of surgery, have resulted in only modest weight loss in the long term.5 More limited research on the prevention and treatment of obesity in children suggests that school based programmes may be effective.6-8 Almost no data exist on the effectiveness of public health initiatives. The lack of evidence does not condone inaction or delay. On the contrary, we must create the evidence. Adopted policies need to be tested scientifically, in well designed controlled studies, in order to evaluate and document the usefulness of each tactic. The many recommendations made by the health committee are idealistic and expensive. Funding limitations will require us to choose among proposals. Thus finding the most successful and cost effective policies will be crucial. As suggested in the report, when each initiative is implemented, a parallel process of evaluating its impact must be put into place. Much research on obesity is hampered by our inability to measure food intake and energy expenditure accurately.6 Even more than in clinical studies, health policy research in obesity depends on reliable assessments of caloric intake and physical activity to assess the effects of interventions among large groups of people. Inevitably the interest of the government and the public to support health will collide with the food industrys desire for profit if not immediately then soon. When such conflicts arise, the winning argument will be the one that can prove with hard evidence that their strategy works to combat obesity and promote health.

Where all the children are above average.

In this issue of Pediatrics , Ben-Joseph et al1 report that parents often misunderstand growth-chart information about their child. On the basis of a nationally representative Web-based survey with 1000 parent-respondents, the authors confirm that the ability to comprehend and interpret complex graphical information such as the current Centers for Disease Control and Prevention growth charts requires sophisticated mathematical skills that are not universal among US parents, especially those with limited education. In the face of the current epidemic of childhood obesity, it is increasingly important to accurately convey to parents a childs growth parameters and risk of obesity and its consequences. Together with several studies2–4 that have described that parents often do not believe that overweight children are overweight or at risk of poor health and the widespread notion that children outgrow their “baby fat,” the present study underscores how poorly we as clinicians are getting through to parents. By looking closely at the current study results, one can discern a small clue about why it is difficult to communicate concern about childhood … Address correspondence to Anjali Jain, MD, Childrens National Medical Center and George Washington University, Center for Health Services and Community Research, Childrens Research Institute, Room 5536, 111 Michigan Ave, Washington, DC 20010. E-mail: ajain{at}cnmc.org

Correction of Description of MMR Vaccine Receipt Coding and Minor Errors in MMR Vaccine and Autism Study

To the Editor This letter is in reference to our article “Autism Occurrence by MMR Vaccine Status Among US Children With Older Siblings With and Without Autism,” which was published in the April 21, 2015, issue of JAMA.1 We recently undertook a review of this report and discovered an incorrect description of when the measles-mumps-rubella (MMR) vaccine was received. As detailed below, correcting this error, as well as other minor errors, did not have a material effect on the findings of the study and the conclusion remains that the MMR vaccination was not associated with an increased risk of autism spectrum disorders (ASD).