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Article| Volume 14, ISSUE 5, SUPPLEMENT , S68-S75, September 01, 2014

Quality Concerns in Antipsychotic Prescribing for Youth: A Review of Treatment Guidelines

DOI:https://doi.org/10.1016/j.acap.2014.05.009
Quality Concerns in Antipsychotic Prescribing for Youth: A Review of Treatment Guidelines
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      Abstract

      Background

      Antipsychotic prescribing for youth has increased rapidly, is linked with serious health concerns, and lacks clear measures of quality for pediatric care. We reviewed treatment guidelines relevant to 7 quality concepts for appropriate use and management of youth on antipsychotics: 1) use in very young children, 2) multiple concurrent antipsychotics, 3) higher-than-recommended doses, 4) use without a primary indication, 5) access to psychosocial interventions, 6) metabolic screening, and 7) follow-up visits with a prescriber.

      Methods

      We searched for clinical practice guidelines meeting the following criteria: developed or endorsed by a national body, published after 2000, and specific treatment recommendations made related to 1 or more of the 7 quality concepts. Sources included electronic databases, the American Academy of Child and Adolescent Psychiatry Web site, and stakeholder and expert advisory committee recommendations. Two raters reviewed the 11 guidelines identified, extracting treatment recommendations, including details that could support measure definitions, and ratings of strength of recommendation and evidence.

      Results

      All 7 quality concepts were strongly endorsed by 1 or more guidelines, and 2 or more guidelines assigned their highest strength of recommendation ratings to 6 of the 7 concepts. Two guidelines rated evidence, providing high strength of evidence for 2 quality concepts: psychosocial interventions and metabolic monitoring.

      Conclusions

      Guidelines provide support for 7 quality concepts addressing antipsychotic prescribing for youth. However, guideline support is often based on strong clinical consensus rather than a robust evidence base.

      Keywords

      Antipsychotic prescribing for children has increased 2- to 4-fold over the past 15 years,
      • Seida J.C.
      • Schouten J.R.
      • Boylan K.
      • et al.
      Antipsychotics for children and young adults: a comparative effectiveness review.
      Pediatrics. 2012; 129: e771-e784
      , 
      • Crystal S.
      • Olfson M.
      • Huang C.
      • et al.
      Broadened use of atypical antipsychotics: safety, effectiveness, and policy challenges.
      Health Aff (Millwood). 2009; 28: w770-w781
      raising several public health concerns. The majority of antipsychotic prescribing in children is for nonpsychotic conditions such as attention-deficit/hyperactivity disorder and disruptive behaviors.
      • Penfold R.B.
      • Stewart C.
      • Hunkeler E.M.
      • et al.
      Use of antipsychotic medications in pediatric populations: what do the data say?.
      Curr Psychiatry Rep. 2013; 15: 426
      Vulnerable child populations, including minorities,
      • Adams S.J.
      • Xu S.
      • Dong F.
      Differences in Prescribing Patterns of Psychotropic Medication for Children and Adolescents Between Rural and Urban Prescribers.
      WICHE Center for Rural Mental Health Research, Boulder, Colo2009
      Medicaid enrollees,
      • Crystal S.
      • Olfson M.
      • Huang C.
      • et al.
      Broadened use of atypical antipsychotics: safety, effectiveness, and policy challenges.
      Health Aff (Millwood). 2009; 28: w770-w781
      and those in foster care,
      • Medicaid Medical Directors Learning Network
      Rutgers Center for Education and Research on Mental Health Therapeutics Antipsychotic Medication Use in Medicaid Children and Adolescents. Report and Resource Guide From a 16-State Study.
      MMDLN/Rutgers CERT, New Brunswick, NJ2010
      are more likely to be prescribed antipsychotics. Antipsychotics can have serious adverse effects with long-term health implications, including diabetes and hyperlipidemia, movement disorders, and hyperprolactinemia.
      • Maglione M.
      • Maher A.R.
      • Hu J.
      • et al.
      Off-Label Use of Atypical Antipsychotics: An Update.
      Agency for Healthcare Research and Quality, Rockville, Md2011
      , 
      • Correll C.U.
      • Manu P.
      • Olshanskiy V.
      • et al.
      Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents.
      JAMA. 2009; 302: 1765-1773
      , 
      • Seida J.C.
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      • Mousavi S.S.
      • et al.
      First- and Second-Generation Antipsychotics for Children and Young Adults.
      Agency for Healthcare Research and Quality, Rockville, Md2012
      Especially worrisome is the limited evidence on the long-term safety of antipsychotic prescribing in children.
      • Seida J.C.
      • Schouten J.R.
      • Boylan K.
      • et al.
      Antipsychotics for children and young adults: a comparative effectiveness review.
      Pediatrics. 2012; 129: e771-e784
      , 
      • Jensen P.S.
      • Buitelaar J.
      • Pandina G.J.
      • et al.
      Management of psychiatric disorders in children and adolescents with atypical antipsychotics: a systematic review of published clinical trials.
      Eur Child Adolesc Psychiatry. 2007; 16: 104-120
      These concerns have prompted calls for monitoring antipsychotic use in children, especially those in foster care and others covered by Medicaid or the Children's Health Insurance Program (CHIP).
      • Medicaid Medical Directors Learning Network
      Rutgers Center for Education and Research on Mental Health Therapeutics Antipsychotic Medication Use in Medicaid Children and Adolescents. Report and Resource Guide From a 16-State Study.
      MMDLN/Rutgers CERT, New Brunswick, NJ2010
      , 
      • Administration on Children
      Youth, and Families.
      Information Memorandum on Promoting the Safe, Appropriate, and Effective Use of Psychotropic Medication for Children in Foster Care. US Dept of Health and Human Services, Washington, DC2012
      , 
      • Stambaugh L.
      • Leslie L.K.
      • Ringeisen H.
      • et al.
      Psychotropic Medication Use by Children in Child Welfare.
      Office of Planning, Research, and Evaluation; Administration for Children and Families; US Dept of Health and Human Services, Washington, DC2012
      Quality measurement is one approach to monitoring, but few pediatric mental health measures exist.
      • Zima B.T.
      • Murphy J.M.
      • Scholle S.H.
      • et al.
      National quality measures for child mental health care: background, progress, and next steps.
      Pediatrics. 2013; 131: S38-S49
      The Children's Health Insurance Program Reauthorization Act of 2009 Pediatric Quality Measure Program (PQMP) focuses on development and dissemination of new pediatric measures for Medicaid and CHIP. The National Collaborative for Innovation in Quality Measurement (NCINQ), a PQMP Center of Excellence, was tasked by the Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services (CMS) to develop antipsychotic quality measures for children and adolescents.
      • Byron S.C.
      • Gardner W.
      • Kleinman L.
      • Mangione-Smith R.
      • et al.
      Developing measures for pediatric quality: methods and experiences of the pediatric quality measures program.
      Acad Pediatr. 2014; 14: S27-S32
      Consistent with CMS's Blueprint,
      • Health Services Advisory Group Inc
      A Blueprint for the CMS Measures Management System.
      Health Services Advisory Group Inc, Phoeniz, Ariz2012
      and as described in more detail elsewhere,
      • Byron S.C.
      • Gardner W.
      • Kleinman L.
      • Mangione-Smith R.
      • et al.
      Developing measures for pediatric quality: methods and experiences of the pediatric quality measures program.
      Acad Pediatr. 2014; 14: S27-S32
      early steps in measure development include a review of existing and related measures and obtaining guidance from multiple stakeholders on priorities. NCINQ invited input from federal officials (including from Medicaid and CHIP), clinicians, patient and family advocates, state officials, and subject matter experts on concepts, including earlier antipsychotic measure development efforts by multistate quality collaboratives.
      • Medicaid Medical Directors Learning Network
      Rutgers Center for Education and Research on Mental Health Therapeutics Antipsychotic Medication Use in Medicaid Children and Adolescents. Report and Resource Guide From a 16-State Study.
      MMDLN/Rutgers CERT, New Brunswick, NJ2010
      , 

      Rutgers University Institute for Health, Health Care Policy, and Aging. Accelerating utilization of comparative effectiveness findings in Medicaid mental health: Medicaid Network for Evidence-based Treatment (MEDNET). Available at: http://www.academyhealth.org/files/FileDownloads/MEDNET.pdf. Accessed April 3, 2014.

      , 

      Center for Health Care Strategies Inc. Improving the use of psychotropic medication among children and youth in foster care: a quality improvement collaborative. Available at: http://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=1261326. Accessed April 3, 2014.

      The stakeholder advisory committees (Online Supplement A) identified 7 high-priority measure concepts. Four concepts address appropriateness/overuse of antipsychotics in children: 1) use in very young children, 2) multiple concurrent antipsychotics, 3) higher-than-recommended doses, and 4) use without a primary indication. Three additional concepts address management of children receiving antipsychotic therapy: 5) access to psychosocial interventions, 6) metabolic screening, and 7) follow-up visits with a prescriber.
      Clinical practice guidelines (CPGs) that summarize research and provide clinical recommendations have been used to develop guidance for states on psychotropic medications
      • Administration on Children
      Youth, and Families.
      Information Memorandum on Promoting the Safe, Appropriate, and Effective Use of Psychotropic Medication for Children in Foster Care. US Dept of Health and Human Services, Washington, DC2012
      and can play a critical role in the information-gathering stage of quality measure development.
      • Health Services Advisory Group Inc
      A Blueprint for the CMS Measures Management System.
      Health Services Advisory Group Inc, Phoeniz, Ariz2012
      First, CPGs can inform the decision to move forward with measure development. Ideally, measure concepts are supported by strong recommendations and high ratings of evidence by national guidelines. Second, guidelines may provide details that refine measure concepts or inform measure definitions. Here we report on the NCINQ team's review of CPG recommendations relevant to the 7 quality concepts prioritized by stakeholders. We summarize relevant antipsychotic treatment recommendations, ratings of strength of recommendations (SOR) and evidence (SOE), and discuss implications for measure development. This information may be of clinical and policy interest, building on Administration for Children and Families' approach to developing guidance for states on psychotropic medications on the basis of endorsement by 2 or more guidelines
      • Administration on Children
      Youth, and Families.
      Information Memorandum on Promoting the Safe, Appropriate, and Effective Use of Psychotropic Medication for Children in Foster Care. US Dept of Health and Human Services, Washington, DC2012
      in addition to contributing to NCINQ's measure development efforts.

      Methods

      The initial search was conducted April 2012 and was updated in September 2013. Guideline inclusion criteria were: 1) addressed measure concepts, 2) English-language publication in the United States since 2000, and 3) issued or used by a national organization, or developed with input from a national workgroup or advisory panel. First we conducted a search of the National Guidelines Clearinghouse and Guidelines International Network, PubMed, and PsychInfo using: “antipsychotic,” “youth OR child* OR adolescen*,” ”guideline OR algorithm,” yielding 5 guidelines meeting criteria.
      • McClellan J.
      • Kowatch R.
      • Findling R.L.
      Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 107-125
      , 
      • Steiner H.
      • Remsing L.
      Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 126-141
      , 
      • Scotto Rosato N.
      • Correll C.U.
      • Pappadopulos E.
      • et al.
      Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management.
      Pediatrics. 2012; 129: e1577-e1586
      , 
      • Gleason M.M.
      • Egger H.L.
      • Emslie G.J.
      • et al.
      Psychopharmacological treatment for very young children: contexts and guidelines.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 1532-1572
      , 
      • Pappadopulos E.
      • Macintyre Ii J.C.
      • Crismon M.L.
      • et al.
      Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part II.
      J Am Acad Child Adolesc Psychiatry. 2003; 42: 145-161
      Second, the Web site of the leading child psychiatry professional association (American Academy of Child and Adolescent Psychiatry, AACAP) was examined, yielding 3 additional guidelines.

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      , 
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter on the use of psychotropic medication in children and adolescents.
      J Am Acad Child Adolesc Psychiatry. 2009; 48: 961-973
      , 
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter for the assessment and treatment of children and adolescents with schizophrenia.
      J Am Acad Child Adolesc Psychiatry. 2001; 40: 4S-23S
      Finally, 3 guidelines were recommended by the advisory panels: a Texas guideline

      Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.

      used by the national Medicaid Medical Directors Learning Network,
      • Medicaid Medical Directors Learning Network
      Rutgers Center for Education and Research on Mental Health Therapeutics Antipsychotic Medication Use in Medicaid Children and Adolescents. Report and Resource Guide From a 16-State Study.
      MMDLN/Rutgers CERT, New Brunswick, NJ2010
      a Canadian guideline
      • Pringsheim T.
      • Panagiotopoulos C.
      • Davidson J.
      • Ho J.
      Evidence-based recommendations for monitoring safety of second generation antipsychotics in children and youth.
      J Can Acad Child Adolesc Psychiatry. 2011; 20: 218-233
      considered highly relevant and methodologically rigorous, and the American Psychiatric Associations' Choosing Wisely recommendations.

      American Psychiatric Association. Choosing Wisely. Available at: http://www.choosingwisely.org/doctor-patient-lists/american-psychiatric-association/. Accessed October 21, 2013.

      The 11 identified guidelines, including abbreviations used throughout, are summarized in Table 1. Two raters (EK, MF) reviewed the guidelines to extract relevant treatment recommendations and ratings of SOR and SOE. Seven guidelines provided formal ratings of their recommendations, but used different rating systems, and only two
      • Pringsheim T.
      • Panagiotopoulos C.
      • Davidson J.
      • Ho J.
      Evidence-based recommendations for monitoring safety of second generation antipsychotics in children and youth.
      J Can Acad Child Adolesc Psychiatry. 2011; 20: 218-233
      , 
      • Scotto Rosato N.
      • Correll C.U.
      • Pappadopulos E.
      • et al.
      Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management.
      Pediatrics. 2012; 129: e1577-e1586
      followed Institute of Medicine standards
      • Institute of Medicine
      Clinical Practice Guidelines We Can Trust.
      Institute of Medicine, Washington, DC2011
      for rating both SOR and SOE. To support comparisons across guidelines, the authors mapped CPG ratings to general categories of strong, moderate, or weak (Table 2).
      Table 1National Guidelines Identified for Review Related to NCINQ Pediatric Antipsychotic Measure Concepts
      Abbreviated NameSponsoring Organization and Guideline TitleYearPopulationBrief Description
      AACAP-AAAAACAP—Practice parameter for the use of atypical antipsychotic medications in children and adolescents

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      		2011 Web5–18 y19 recommendations on the use of atypical antipsychotics in children, rated using AACAP rating system.
      AACAP rating system is used for most AACAP guidelines (see Table 2 for definitions).
      AACAP-PsyMedAACAP—Practice parameter on the use of psychotropic medication in children and adolescents
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter on the use of psychotropic medication in children and adolescents.
      J Am Acad Child Adolesc Psychiatry. 2009; 48: 961-973
      		2009≤18 y13 best practice principles that underlie psychotropic medication prescribing for children (unrated).
      AACAP-BPAACAP—Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder
      • McClellan J.
      • Kowatch R.
      • Findling R.L.
      Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 107-125
      		2007≤18 y, bipolar disorder11 recommendations on the treatment of bipolar disorder in children, rated using AACAP rating system.
      AACAP rating system is used for most AACAP guidelines (see Table 2 for definitions).
      AACAP-ODDAACAP—Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder
      • Steiner H.
      • Remsing L.
      Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 126-141
      		2007≤18 y, oppositional defiant disorder11 recommendations on the treatment of oppositional defiant disorder, rated using AACAP rating system.
      AACAP rating system is used for most AACAP guidelines (see Table 2 for definitions).
      AACAP-SZAACAP—Practice parameter for the assessment and treatment of children and adolescents with schizophrenia
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter for the assessment and treatment of children and adolescents with schizophrenia.
      J Am Acad Child Adolesc Psychiatry. 2001; 40: 4S-23S
      		2001≤18 y, schizophreniaRecommendations are embedded within a summary of the literature on treatment of schizophrenia in children, with some recommendations rated using AACAP system.
      AACAP rating system is used for most AACAP guidelines (see Table 2 for definitions).
      CAMESACAMESA—Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children—Evidence-based recommendations for monitoring safety of second generation antipsychotics in children and youth
      • Pringsheim T.
      • Panagiotopoulos C.
      • Davidson J.
      • Ho J.
      Evidence-based recommendations for monitoring safety of second generation antipsychotics in children and youth.
      J Can Acad Child Adolesc Psychiatry. 2011; 20: 218-233
      		2011≤18 y, on antipsychoticMonitoring tests for children on antipsychotics are rated for SOR and SOE for 10 laboratory and 6 physical examination tests for each of 6 atypical antipsychotics, at 4 time points (baseline, 3, 6, and 12 mo) using the GRADE
      • Andrews J.C.
      • Schunemann H.J.
      • Oxman A.D.
      • et al.
      GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation’s direction and strength.
      J Clin Epidemiol. 2013; 66: 726-735
      , 
      • Guyatt G.H.
      • Oxman A.D.
      • Vist G.E.
      • et al.
      GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
      BMJ. 2008; 336: 924-926
      system (total of 384 rated recommendations).
      PPWGAACAP-sponsored Preschool Psychopharmacology Working Group—Psychopharmacological treatment for very young children: Contexts and guidelines
      • Gleason M.M.
      • Egger H.L.
      • Emslie G.J.
      • et al.
      Psychopharmacological treatment for very young children: contexts and guidelines.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 1532-1572
      		2007<6 y9 treatment algorithms for the treatment of 9 diagnoses in preschool aged children with rated recommendations for each stage of the algorithm using an adaptation of the AACAP rating system.
      AACAP rating system is used for most AACAP guidelines (see Table 2 for definitions).
      TRAAYCenter for the Advancement of Children's Mental Health—Treatment recommendations for the use of antipsychotics for aggressive youth
      • Pappadopulos E.
      • Macintyre Ii J.C.
      • Crismon M.L.
      • et al.
      Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part II.
      J Am Acad Child Adolesc Psychiatry. 2003; 42: 145-161
      		2003≤18 y, aggression14 recommendations on the use of antipsychotics in the treatment of aggression in youth. Formal consensus methods are used and recommendations are unrated.
      T-MAYCenter for Education and Research on Mental Health Therapeutics—Treatment of maladaptive aggression in youth
      • Scotto Rosato N.
      • Correll C.U.
      • Pappadopulos E.
      • et al.
      Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management.
      Pediatrics. 2012; 129: e1577-e1586
      		2012≤18 y, aggression20 recommendations on the treatment of aggression in children, with ratings of SOE using Oxford Centre for EBM grading of evidence system

      OCEBM Levels of Evidence Working Group. The Oxford 2011 levels of evidence. Available at: http://www.cebm.net/index.aspx?o=5653. Accessed October 12, 2013.

      and separate SOR ratings.
      TXTexas Department of Family and Protective Services—Psychotropic medication utilization parameters for foster children

      Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.

      		2013Foster care9 psychotropic prescribing practices that trigger a clinical review for children in foster care in Texas (unrated).
      APA-CWAmerican Psychiatric Association—Choosing Wisely

      American Psychiatric Association. Choosing Wisely. Available at: http://www.choosingwisely.org/doctor-patient-lists/american-psychiatric-association/. Accessed October 21, 2013.

      		2013Children and adults5 questionable antipsychotic prescribing practices for children and adults, based on formal consensus methods (modified Delphi, >70% agreement).
      NCINQ indicates National Collaborative for Innovation in Quality Measurement; AACAP, American Academy of Child and Adolescent Psychiatry; SOE, strength of evidence; and SOR, strength of recommendation.
      ∗ AACAP rating system is used for most AACAP guidelines (see Table 2 for definitions).
      Table 2Recommendation Rating Systems and Definitions Used by National Guidelines Related to Pediatric Antipsychotic Use
      Guidelines
      See Table 1 for full names.
      		Rating SystemRating Definition
      To support comparisons of ratings across guidelines, ratings were grouped into the following categories: strong/highest, moderate, or weak.
      Strong/Highest RatingModerate RatingWeak RatingNot Endorsed
      Most guidelines used a “strong” recommendation against rather than “not endorsed” to indicate that a practice should be avoided.
      AACAP-AAA, AACAP-BP AACAP-ODD, AACAP-SZAACAP rating system
      AACAP rating system is used for most AACAP guidelines.
      		Minimal standard/clinical standard: Rigorous/substantial empirical evidence (meta-analyses, systematic reviews, RCTs) and/or overwhelming clinical consensus; expected to apply more than 95% percent of the timeClinical guideline: Strong empirical evidence (nonrandomized controlled trials, cohort or case-control studies), and/or strong clinical consensus; expected to apply in most cases (75% of the time)Options: Acceptable but not required; there may be insufficient evidence to support higher recommendation (uncontrolled trials, case/series reports)Not endorsed: Ineffective or contraindicated
      CAMESAGRADE
      • Andrews J.C.
      • Schunemann H.J.
      • Oxman A.D.
      • et al.
      GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation’s direction and strength.
      J Clin Epidemiol. 2013; 66: 726-735
      system (includes SOR and SOE ratings)      		SOR strong: 1A, 1B, 1CSOR weak: 2A, 2B, 3
      SOE high: 1A, 2ASOE moderate: 2ASOE low: 1C, 2B, 3
      PPWGAdaptation of AACAP rating systemA: Well-controlled RCTs, large meta-analyses, or overwhelming clinical consensusB: Empirical evidence (open trials, case series) or strong clinical consensusC: Single case reports or no published reports, recommendation developed by expert consensus (informal)
      T-MAYOxford Centre for EBM grading of evidence (A-D) system

      OCEBM Levels of Evidence Working Group. The Oxford 2011 levels of evidence. Available at: http://www.cebm.net/index.aspx?o=5653. Accessed October 12, 2013.

      for SOE and separate SOR ratings      		SOR very strong: ≥90% agreementSOR strong: 70–89% agreementSOR fair: 50–69% agreementSOR weak: <50% agreement
      SOE A: Consistent level 1 studies (eg, RCT)SOE B: Consistent level 2 or 3 studies (eg, cohort or case control studies) or extrapolations from level 1 studies, BSOE C: Level 4 studies (eg, case studies) or extrapolations from level 2 or 3 studiesSOE D: Level 5 evidence (eg, expert opinion without explicit critical appraisal) or troublingly inconsistent or inconclusive studies of any level
      RCT indicates randomized controlled trial; SOE, strength of evidence; and SOR, strength of recommendation.
      ∗ See Table 1 for full names.
      † To support comparisons of ratings across guidelines, ratings were grouped into the following categories: strong/highest, moderate, or weak.
      ‡ Most guidelines used a “strong” recommendation against rather than “not endorsed” to indicate that a practice should be avoided.
      § AACAP rating system is used for most AACAP guidelines.

      Results

      Table 3 summarizes guideline ratings for each quality concept, categorized as strong, moderate, or weak. Detailed treatment recommendations and ratings extracted from guidelines are summarized for each concept in Online Supplement B. Guideline recommendations and ratings for each quality concept are described below, highlighting similarities and differences.
      Table 3Strength of Recommendations and Evidence (When Available) Related to 7 Antipsychotic Measure Concepts
      Guideline
      See Table 1 for full names.
      		Strength of Recommendation and Evidence Ratings
      CAMESA provides ratings of both SOR and SOE and rate each antipsychotic medication, each time interval (0, 3, 6, 12 months) and each test separately. All combinations cannot be shown, but in general, testing is strongly recommended, and evidence is rated highest at 0 and 3 months.
      by Antipsychotic Measure Concept
      Use in Very Young ChildrenMultiple Concurrent AntipsychoticsHigher Than Recommended DosesUse Without a Primary IndicationAccess to Psychosocial InterventionsMetabolic ScreeningFollow-up Visit With Prescriber
      AACAP-AAAStrongStrongModerateStrongStrongStrongStrong
      AACAP-PsyMedUnratedUnrated
      AACAP-BPStrongStrongStrong
      AACAP-ODDModerateStrong
      AACAP-SZStrongStrongStrongStrong
      CAMESA
      CAMESA provides ratings of both SOR and SOE and rate each antipsychotic medication, each time interval (0, 3, 6, 12 months) and each test separately. All combinations cannot be shown, but in general, testing is strongly recommended, and evidence is rated highest at 0 and 3 months.
      		Strong (SOR)
      CPG ratings were categorized as strong/high, moderate, or weak to facilitate comparisons across guidelines (see Table 2). Most guideline rating systems did not rate strength of recommendation and evidence separately. To be conservative, we consider all ratings as SOR unless it is specified that the rating is for SOE.
      , high (SOE)
      CPG ratings were categorized as strong/high, moderate, or weak to facilitate comparisons across guidelines (see Table 2). Most guideline rating systems did not rate strength of recommendation and evidence separately. To be conservative, we consider all ratings as SOR unless it is specified that the rating is for SOE.
      PPWG
      PPWG provides ratings for each step of treatment algorithms for 9 different diagnoses. All combinations cannot be represented; variation exists in ratings by diagnosis and age.
      		Strong–weak
      CAMESA provides ratings of both SOR and SOE and rate each antipsychotic medication, each time interval (0, 3, 6, 12 months) and each test separately. All combinations cannot be shown, but in general, testing is strongly recommended, and evidence is rated highest at 0 and 3 months.
      		Strong–weak
      CAMESA provides ratings of both SOR and SOE and rate each antipsychotic medication, each time interval (0, 3, 6, 12 months) and each test separately. All combinations cannot be shown, but in general, testing is strongly recommended, and evidence is rated highest at 0 and 3 months.
      		Strong–weak
      CAMESA provides ratings of both SOR and SOE and rate each antipsychotic medication, each time interval (0, 3, 6, 12 months) and each test separately. All combinations cannot be shown, but in general, testing is strongly recommended, and evidence is rated highest at 0 and 3 months.
      		UnratedUnrated
      TRAAYUnratedUnratedUnratedUnrated
      T-MAYStrong (SOR), weak (SOE)UnratedUnratedStrong (SOR), high (SOE)Strong (SOR), high (SOE)
      TXUnratedUnratedUnratedUnratedUnratedUnrated
      APA-CWUnrated
      Totals
      CPG with recommendation3457786
      CPG with rated recommendation2223653
      CPGs with SOR = strong2212653
      CPGs with SOE = strong0000120
      CPG indicates clinical practice guidelines; SOR, strength of recommendation; and SOE, strength of evidence.
      ∗ See Table 1 for full names.
      † CAMESA provides ratings of both SOR and SOE and rate each antipsychotic medication, each time interval (0, 3, 6, 12 months) and each test separately. All combinations cannot be shown, but in general, testing is strongly recommended, and evidence is rated highest at 0 and 3 months.
      ‡ CPG ratings were categorized as strong/high, moderate, or weak to facilitate comparisons across guidelines (see Table 2). Most guideline rating systems did not rate strength of recommendation and evidence separately. To be conservative, we consider all ratings as SOR unless it is specified that the rating is for SOE.
      § PPWG provides ratings for each step of treatment algorithms for 9 different diagnoses. All combinations cannot be represented; variation exists in ratings by diagnosis and age.

       Use of Antipsychotics in Very Young Children

      Three guidelines (AACAP-AAA,

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      PPWG,
      • Gleason M.M.
      • Egger H.L.
      • Emslie G.J.
      • et al.
      Psychopharmacological treatment for very young children: contexts and guidelines.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 1532-1572
      and TX

      Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.

      ) address use of antipsychotics in very young children and highlight the lack of data on effectiveness and safety of antipsychotics in this population. AACAP-AAA strongly recommends caution, and a clinical review is triggered under TX guidelines. PPWG endorses psychosocial interventions as the treatment of choice in this age group, recommending antipsychotics only after psychosocial interventions have failed. Guidelines vary in their definition of very young, with AACAP-AAA and PPWG using <6 years of age and Texas using <4 years of age.

       Use of 2 or More Concurrent Antipsychotics

      Four guidelines (AACAP-AAA,

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      AACAP-PsyMed,
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter on the use of psychotropic medication in children and adolescents.
      J Am Acad Child Adolesc Psychiatry. 2009; 48: 961-973
      T-MAY,
      • Scotto Rosato N.
      • Correll C.U.
      • Pappadopulos E.
      • et al.
      Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management.
      Pediatrics. 2012; 129: e1577-e1586
      and TX

      Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.

      ) addressed the concurrent use of 2 or more antipsychotics as a practice to be avoided. AACAP-AAA rates this practice as “not endorsed,” and it triggers a clinical review in the TX parameters. SORs were strong for the 2 guidelines with ratings,
      • Scotto Rosato N.
      • Correll C.U.
      • Pappadopulos E.
      • et al.
      Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management.
      Pediatrics. 2012; 129: e1577-e1586
      , 

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      while the 1 SOE rating was weak.
      • Scotto Rosato N.
      • Correll C.U.
      • Pappadopulos E.
      • et al.
      Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management.
      Pediatrics. 2012; 129: e1577-e1586
      Guidelines clarify that concurrent use may be appropriate when transitioning from one medication to another, but did not specify duration.
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter on the use of psychotropic medication in children and adolescents.
      J Am Acad Child Adolesc Psychiatry. 2009; 48: 961-973

       High Doses of Antipsychotics

      Five guidelines (AACAP-AAA,

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      AACAP-SZ,
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter for the assessment and treatment of children and adolescents with schizophrenia.
      J Am Acad Child Adolesc Psychiatry. 2001; 40: 4S-23S
      TRAAY,
      • Pappadopulos E.
      • Macintyre Ii J.C.
      • Crismon M.L.
      • et al.
      Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part II.
      J Am Acad Child Adolesc Psychiatry. 2003; 42: 145-161
      T-MAY,
      • Scotto Rosato N.
      • Correll C.U.
      • Pappadopulos E.
      • et al.
      Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management.
      Pediatrics. 2012; 129: e1577-e1586
      and TX

      Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.

      ) recommended conservative antipsychotic dosing strategies for children. Three guidelines endorsed a ‘start low and go slow’ approach,
      • Scotto Rosato N.
      • Correll C.U.
      • Pappadopulos E.
      • et al.
      Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management.
      Pediatrics. 2012; 129: e1577-e1586
      , 
      • Pappadopulos E.
      • Macintyre Ii J.C.
      • Crismon M.L.
      • et al.
      Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part II.
      J Am Acad Child Adolesc Psychiatry. 2003; 42: 145-161
      , 

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      which AACAP-AAA rated with a moderate SOR. AACAP-SZ strongly recommended adequate dosing and reassessing dosing needs over time. Only 2 CPGs provided specific dose parameters,
      • Scotto Rosato N.
      • Correll C.U.
      • Pappadopulos E.
      • et al.
      Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management.
      Pediatrics. 2012; 129: e1577-e1586
      , 

      Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.

      while AACAP-AAA states doses for children should not exceed the maximum recommended for adults.

       Use of Antipsychotics without a Primary Indication

      Seven guidelines address use of antipsychotics in the absence of a primary indication such as psychotic disorder.
      • Steiner H.
      • Remsing L.
      Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 126-141
      , 
      • Scotto Rosato N.
      • Correll C.U.
      • Pappadopulos E.
      • et al.
      Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management.
      Pediatrics. 2012; 129: e1577-e1586
      , 
      • Gleason M.M.
      • Egger H.L.
      • Emslie G.J.
      • et al.
      Psychopharmacological treatment for very young children: contexts and guidelines.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 1532-1572
      , 
      • Pappadopulos E.
      • Macintyre Ii J.C.
      • Crismon M.L.
      • et al.
      Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part II.
      J Am Acad Child Adolesc Psychiatry. 2003; 42: 145-161
      , 

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      , 

      Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.

      , 

      American Psychiatric Association. Choosing Wisely. Available at: http://www.choosingwisely.org/doctor-patient-lists/american-psychiatric-association/. Accessed October 21, 2013.

      Guidelines consistently recommend psychosocial treatments and safer medications before advancing to antipsychotics, with AACAP-AAA

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      rating the SOR as strong. Two other CPGs provide ratings of use of antipsychotics as second- or third-line treatment options, with SORs of strong to weak depending upon the child's age and diagnosis.
      • Steiner H.
      • Remsing L.
      Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 126-141
      , 
      • Gleason M.M.
      • Egger H.L.
      • Emslie G.J.
      • et al.
      Psychopharmacological treatment for very young children: contexts and guidelines.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 1532-1572

       Psychosocial Services

      Seven guidelines address psychosocial services in the context of antipsychotic prescribing for children.
      • McClellan J.
      • Kowatch R.
      • Findling R.L.
      Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 107-125
      , 
      • Steiner H.
      • Remsing L.
      Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 126-141
      , 
      • Scotto Rosato N.
      • Correll C.U.
      • Pappadopulos E.
      • et al.
      Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management.
      Pediatrics. 2012; 129: e1577-e1586
      , 
      • Gleason M.M.
      • Egger H.L.
      • Emslie G.J.
      • et al.
      Psychopharmacological treatment for very young children: contexts and guidelines.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 1532-1572
      , 
      • Pappadopulos E.
      • Macintyre Ii J.C.
      • Crismon M.L.
      • et al.
      Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part II.
      J Am Acad Child Adolesc Psychiatry. 2003; 42: 145-161
      , 

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      , 
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter for the assessment and treatment of children and adolescents with schizophrenia.
      J Am Acad Child Adolesc Psychiatry. 2001; 40: 4S-23S
      Psychosocial services are recommended as first-line treatment for very young children,
      • Gleason M.M.
      • Egger H.L.
      • Emslie G.J.
      • et al.
      Psychopharmacological treatment for very young children: contexts and guidelines.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 1532-1572
      youth with aggression,
      • Scotto Rosato N.
      • Correll C.U.
      • Pappadopulos E.
      • et al.
      Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management.
      Pediatrics. 2012; 129: e1577-e1586
      , 
      • Pappadopulos E.
      • Macintyre Ii J.C.
      • Crismon M.L.
      • et al.
      Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part II.
      J Am Acad Child Adolesc Psychiatry. 2003; 42: 145-161
      and children with disruptive behavior disorders.
      • Steiner H.
      • Remsing L.
      Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 126-141
      In the absence of a primary indication, guidelines recommend psychosocial treatments before initiating an antipsychotic with strong SOR ratings,
      • Steiner H.
      • Remsing L.
      Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 126-141
      , 
      • Scotto Rosato N.
      • Correll C.U.
      • Pappadopulos E.
      • et al.
      Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management.
      Pediatrics. 2012; 129: e1577-e1586
      , 
      • Gleason M.M.
      • Egger H.L.
      • Emslie G.J.
      • et al.
      Psychopharmacological treatment for very young children: contexts and guidelines.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 1532-1572
      , 

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      while concomitant psychosocial services for youth with schizophrenia
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter for the assessment and treatment of children and adolescents with schizophrenia.
      J Am Acad Child Adolesc Psychiatry. 2001; 40: 4S-23S
      and bipolar disorder
      • McClellan J.
      • Kowatch R.
      • Findling R.L.
      Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 107-125
      also had strong SOR ratings. Some guidelines recommended type and duration of psychosocial interventions.
      • Steiner H.
      • Remsing L.
      Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 126-141
      , 
      • Gleason M.M.
      • Egger H.L.
      • Emslie G.J.
      • et al.
      Psychopharmacological treatment for very young children: contexts and guidelines.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 1532-1572
      , 
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter for the assessment and treatment of children and adolescents with schizophrenia.
      J Am Acad Child Adolesc Psychiatry. 2001; 40: 4S-23S

       Metabolic Screening

      Eight guidelines recommend glucose and lipid screening for children prescribed antipsychotics.
      • McClellan J.
      • Kowatch R.
      • Findling R.L.
      Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 107-125
      , 
      • Pringsheim T.
      • Panagiotopoulos C.
      • Davidson J.
      • Ho J.
      Evidence-based recommendations for monitoring safety of second generation antipsychotics in children and youth.
      J Can Acad Child Adolesc Psychiatry. 2011; 20: 218-233
      , 
      • Scotto Rosato N.
      • Correll C.U.
      • Pappadopulos E.
      • et al.
      Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management.
      Pediatrics. 2012; 129: e1577-e1586
      , 
      • Gleason M.M.
      • Egger H.L.
      • Emslie G.J.
      • et al.
      Psychopharmacological treatment for very young children: contexts and guidelines.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 1532-1572
      , 
      • Pappadopulos E.
      • Macintyre Ii J.C.
      • Crismon M.L.
      • et al.
      Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part II.
      J Am Acad Child Adolesc Psychiatry. 2003; 42: 145-161
      , 

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      , 
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter for the assessment and treatment of children and adolescents with schizophrenia.
      J Am Acad Child Adolesc Psychiatry. 2001; 40: 4S-23S
      , 

      Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.

      The specificity of recommendations for ongoing metabolic monitoring varies, with some guidelines recommending “appropriate” monitoring
      • Gleason M.M.
      • Egger H.L.
      • Emslie G.J.
      • et al.
      Psychopharmacological treatment for very young children: contexts and guidelines.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 1532-1572
      , 

      Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.

      and others identifying specific tests and follow-up intervals.
      • Pringsheim T.
      • Panagiotopoulos C.
      • Davidson J.
      • Ho J.
      Evidence-based recommendations for monitoring safety of second generation antipsychotics in children and youth.
      J Can Acad Child Adolesc Psychiatry. 2011; 20: 218-233
      , 

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      AACAP practice parameters
      • McClellan J.
      • Kowatch R.
      • Findling R.L.
      Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 107-125
      , 

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      endorse the consensus statement of the American Diabetes Association and American Psychiatric Association
      • American Diabetes Association
      • American Psychiatric Association
      American Association of Clinical Endocrinologists; North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes.
      J Clin Psychiatry. 2004; 65: 267-272
      for fasting glucose and fasting lipid profile, while CAMESA
      • Pringsheim T.
      • Panagiotopoulos C.
      • Davidson J.
      • Ho J.
      Evidence-based recommendations for monitoring safety of second generation antipsychotics in children and youth.
      J Can Acad Child Adolesc Psychiatry. 2011; 20: 218-233
      calls for more frequent monitoring in youth and additional monitoring of fasting insulin. Of the 5 guidelines with ratings,
      • McClellan J.
      • Kowatch R.
      • Findling R.L.
      Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 107-125
      , 
      • Pringsheim T.
      • Panagiotopoulos C.
      • Davidson J.
      • Ho J.
      Evidence-based recommendations for monitoring safety of second generation antipsychotics in children and youth.
      J Can Acad Child Adolesc Psychiatry. 2011; 20: 218-233
      , 
      • Scotto Rosato N.
      • Correll C.U.
      • Pappadopulos E.
      • et al.
      Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management.
      Pediatrics. 2012; 129: e1577-e1586
      , 

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      , 
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter for the assessment and treatment of children and adolescents with schizophrenia.
      J Am Acad Child Adolesc Psychiatry. 2001; 40: 4S-23S
      SORs are strong for baseline and ongoing monitoring, while CAMESA SOE ratings highlight higher evidence for baseline than follow-up, and differences among tests and medications.

       Follow-up Visits

      Six guidelines
      • McClellan J.
      • Kowatch R.
      • Findling R.L.
      Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 107-125
      , 
      • Gleason M.M.
      • Egger H.L.
      • Emslie G.J.
      • et al.
      Psychopharmacological treatment for very young children: contexts and guidelines.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 1532-1572
      , 

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      , 
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter on the use of psychotropic medication in children and adolescents.
      J Am Acad Child Adolesc Psychiatry. 2009; 48: 961-973
      , 
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter for the assessment and treatment of children and adolescents with schizophrenia.
      J Am Acad Child Adolesc Psychiatry. 2001; 40: 4S-23S
      , 

      Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.

      address follow-up with a prescriber for children and adolescents on antipsychotics, and the 3 guidelines that provide ratings characterize SORs as strong.
      • McClellan J.
      • Kowatch R.
      • Findling R.L.
      Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 107-125
      , 

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      , 
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter for the assessment and treatment of children and adolescents with schizophrenia.
      J Am Acad Child Adolesc Psychiatry. 2001; 40: 4S-23S
      Some guidelines specify visit content (assessment of medication efficacy and side effects, dose adjustments, medication adherence, and family support).
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter on the use of psychotropic medication in children and adolescents.
      J Am Acad Child Adolesc Psychiatry. 2009; 48: 961-973
      , 
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter for the assessment and treatment of children and adolescents with schizophrenia.
      J Am Acad Child Adolesc Psychiatry. 2001; 40: 4S-23S
      Visit frequency is specified on the basis of severity of illness
      • American Academy of Child and Adolescent Psychiatry
      Practice parameter for the assessment and treatment of children and adolescents with schizophrenia.
      J Am Acad Child Adolesc Psychiatry. 2001; 40: 4S-23S
      and the need to monitor symptoms
      • Gleason M.M.
      • Egger H.L.
      • Emslie G.J.
      • et al.
      Psychopharmacological treatment for very young children: contexts and guidelines.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 1532-1572
      and side effects.
      • McClellan J.
      • Kowatch R.
      • Findling R.L.
      Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder.
      J Am Acad Child Adolesc Psychiatry. 2007; 46: 107-125
      , 

      American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.

      Discussion

      To our knowledge, ours is the first study to summarize and compare recommendations and ratings for 11 guidelines addressing the use of antipsychotics in children. We build on earlier antipsychotic measure development efforts by multistate quality collaboratives
      • Medicaid Medical Directors Learning Network
      Rutgers Center for Education and Research on Mental Health Therapeutics Antipsychotic Medication Use in Medicaid Children and Adolescents. Report and Resource Guide From a 16-State Study.
      MMDLN/Rutgers CERT, New Brunswick, NJ2010
      , 

      Rutgers University Institute for Health, Health Care Policy, and Aging. Accelerating utilization of comparative effectiveness findings in Medicaid mental health: Medicaid Network for Evidence-based Treatment (MEDNET). Available at: http://www.academyhealth.org/files/FileDownloads/MEDNET.pdf. Accessed April 3, 2014.

      , 

      Center for Health Care Strategies Inc. Improving the use of psychotropic medication among children and youth in foster care: a quality improvement collaborative. Available at: http://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=1261326. Accessed April 3, 2014.

      by summarizing the level of guideline endorsement for stakeholders' high-priority quality concerns.
      All 7 quality concepts were strongly endorsed by 1 or more guidelines, and 2 or more guidelines assigned their highest SOR ratings to 6 of the 7 concepts. Appropriate management concepts (psychosocial interventions, metabolic monitoring, and follow-up visits) had multiple guidelines consistently endorsing access to these services with strong SOR ratings. Appropriate-use recommendations focused on the sequence of treatments (eg, lower dose before higher doses, psychosocial interventions before antipsychotics in very young children or in the absence of a primary indication). Although 2 concepts (psychosocial interventions and metabolic screening) had both high SOR and SOE ratings, other guideline ratings were generally based on clinical consensus rather than scientific evidence. This reliance on consensus highlights both limitations in the evidence base and challenges in research, guideline, and measure development processes.
      First, the current research paradigm in child psychiatry is focused on short-term efficacy and safety trials. Studies that test factors helpful to guidelines and quality measure development such as frequency of follow-up, timing of interventions, and choices and combinations of therapies are not priorities for most research funding agencies. Large health systems and pooled electronic health records may present new opportunities to examine a broader range of quality domains.
      Second, guidelines are often generic in their recommendations for clinical care. Guidelines reviewed here offered some details that could inform measure definitions, including dosing parameters, age thresholds for “very young children,” allowing for concurrent use of multiple antipsychotics while changing medications, and reasons for medical follow-up that suggest frequency intervals. However, because of the heterogeneity of settings, patient populations, insurance and public health systems, and number and level of details needed, guidelines cannot provide recommendations that fully meet the needs of measure developers. For example, guidelines recommend follow-up care but generally did not specify type or duration. A recent Institute of Medicine report
      • Institute of Medicine
      Clinical Practice Guidelines We Can Trust.
      Institute of Medicine, Washington, DC2011
      calling for clearer articulation of detailed recommendations may increase the utility of guidelines to support quality measure development.
      Finally, the measure development process itself requires scientific evidence. The National Quality Forum has standardized domains of testing and review for proposed quality measures.

      National Quality Forum. Review and update of guidance for evaluating evidence and measure testing: draft technical report. NQF Technical Report. October 2, 2013. Available at: http://www.qualityforum.org/Publications/2013/10/Review_and_Update_of_Guidance_for_Evaluating_Evidence_and_Measure_Testing_-_Technical_Report.aspx. Accessed February 10, 2014.

      Moving from a quality concept to a fully specified measure requires multiple decisions on inclusion and exclusion criteria, periods of observation, and definitions of elements such as medication classifications, duration of medication trials, and visit type. A recent validation study of antipsychotic polypharmacy measures highlights the impact that varying definitions such as duration of concurrent use have on the operating characteristics of the measure.
      • Leckman-Westin E.
      • Kealey E.
      • Gupta N.
      • et al.
      Validation of a claims-based antipsychotic polypharmacy measure.
      Pharmacoepi Drug Safety. 2014; 23: 628-635
      Evidence-informed consensus is needed on the types of standards most appropriate for different types of measure constructs, technical specifications, and testing domains. Guidance issued by the National Quality Forum

      National Quality Forum. Review and update of guidance for evaluating evidence and measure testing: draft technical report. NQF Technical Report. October 2, 2013. Available at: http://www.qualityforum.org/Publications/2013/10/Review_and_Update_of_Guidance_for_Evaluating_Evidence_and_Measure_Testing_-_Technical_Report.aspx. Accessed February 10, 2014.

      on evaluating evidence and measure testing may support development of measures that provide insight into population-based trends as well as individual prescribing practices.
      Multiple stakeholders have identified the growing use of antipsychotics in children as an area of concern, but the lack of quality measures in this domain (as in other areas of child behavioral services
      • Zima B.T.
      • Murphy J.M.
      • Scholle S.H.
      • et al.
      National quality measures for child mental health care: background, progress, and next steps.
      Pediatrics. 2013; 131: S38-S49
      ) complicates efforts to monitor and assess use. Robust quality measures are a critical tool for improving outcomes, increasing accountability, and aligning systems, providers, and patients toward common outcome and quality goals. On the basis of the guideline review presented here, NCINQ's multiple and diverse stakeholder advisory committees recommended moving forward with all proposed measure concepts, citing the importance of the topic and noting the measures address an opportunity to improve care for an area of urgent public health concern. The guideline review also helped inform measure definitions, which were refined through testing in Medicaid and managed care data and continued advisory panel reviews. As with other measures developed through the PQMP, the measures may be considered for implementation in national programs and will be made publicly available to support quality improvement and clinical decision making.

      Acknowledgments

      This project was supported by grant U18HS020503 (PI: Scholle) from the Agency for Healthcare Research and Quality (AHRQ) and Centers for Medicare and Medicaid Services . The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

      Supplementary Data

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      Article Info

      Publication History

      Accepted: May 21, 2014
      Received: November 6, 2013

      Footnotes

      Dr Hoagwood, Dr Kelleher, Dr Kealey, and Dr Leckman-Westin report no conflicts of interest. Dr Finnerty has been the PI on research grants/contracts from Bristol Myers Squibb and Sunovion, but her time on these projects is in kind. Dr Scholle and Ms Byron work for the National Committee for Quality Assurance, a not-for-profit organization that develops and maintains quality measures.

      Publication of this article was supported by the US Department of Health and Human Services and the Agency for Healthcare Research and Quality.

      The views expressed in this article are those of the authors and do not necessarily represent the views of the US Department of Health and Human Services or the Agency for Healthcare Research and Quality.

      Identification

      DOI: https://doi.org/10.1016/j.acap.2014.05.009

      Copyright

      © 2014 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

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