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      Clinical predictors of antipsychotic use in children and adolescents with autism spectrum disorders: a historical open cohort study using electronic health records

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          Abstract

          Children with autism spectrum disorders (ASD) are more likely to receive antipsychotics than any other psychopharmacological medication, yet the psychiatric disorders and symptoms associated with treatment are unclear. We aimed to determine the predictors of antipsychotic use in children with ASD receiving psychiatric care. The sample consisted of 3482 children aged 3–17 with an ICD-10 diagnosis of ASD referred to mental health services between 2008 and 2013. Antipsychotic use outcome, comorbid diagnoses, and other clinical covariates, including challenging behaviours were extracted from anonymised patient records. Of the 3482 children (79 % male) with ASD, 348 (10 %) received antipsychotic medication. The fully adjusted model indicated that comorbid diagnoses including hyperkinetic (OR 1.44, 95 %CI 1.01–2.06), psychotic (5.71, 3.3–10.6), depressive (2.36, 1.37–4.09), obsessive–compulsive (2.31, 1.16–4.61) and tic disorders (2.76, 1.09–6.95) were associated with antipsychotic use. In addition, clinician-rated levels of aggression, self-injurious behaviours, reduced adaptive function, and overall parental concern for their child’s presenting symptoms were significant risk factors for later antipsychotic use. In ASD, a number of comorbid psychiatric disorders are independent predictors for antipsychotic treatment, even after adjustment for familial, socio-demographic and individual factors. As current trial evidence excludes children with comorbidity, more pragmatic randomised controlled trials with long-term drug monitoring are needed.

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          The online version of this article (doi:10.1007/s00787-015-0780-7) contains supplementary material, which is available to authorized users.

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          Autism diagnostic observation schedule: a standardized observation of communicative and social behavior.

          The Autism Diagnostic Observation Schedule (ADOS), a standardized protocol for observation of social and communicative behavior associated with autism, is described. The instrument consists of a series of structured and semistructured presses for interaction, accompanied by coding of specific target behaviors associated with particular tasks and by general ratings of the quality of behaviors. Interrater reliability for five raters exceeded weighted kappas of .55 for each item and each pair of raters for matched samples of 15 to 40 autistic and nonautistic, mildly mentally handicapped children (M IQ = 59) between the ages of 6 and 18 years. Test-retest reliability was adequate. Further analyses compared these groups to two additional samples of autistic and nonautistic subjects with normal intelligence (M IQ = 95), matched for sex and chronological age. Analyses yielded clear diagnostic differences in general ratings of social behavior, specific aspects of communication, and restricted or stereotypic behaviors and interests. Clinical guidelines for the diagnosis of autism in the draft version of ICD-10 were operationalized in terms of abnormalities on specific ADOS items. An algorithm based on these items was shown to have high reliability and discriminant validity.
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            How evidence-based medicine is failing due to biased trials and selective publication.

            Evidence-based medicine (EBM) was announced in the early 1990s as a 'new paradigm' for improving patient care. Yet there is currently little evidence that EBM has achieved its aim. Since its introduction, health care costs have increased while there remains a lack of high-quality evidence suggesting EBM has resulted in substantial population-level health gains. In this paper we suggest that EBM's potential for improving patients' health care has been thwarted by bias in the choice of hypotheses tested, manipulation of study design and selective publication. Evidence for these flaws is clearest in industry-funded studies. We argue EBM's indiscriminate acceptance of industry-generated 'evidence' is akin to letting politicians count their own votes. Given that most intervention studies are industry funded, this is a serious problem for the overall evidence base. Clinical decisions based on such evidence are likely to be misinformed, with patients given less effective, harmful or more expensive treatments. More investment in independent research is urgently required. Independent bodies, informed democratically, need to set research priorities. We also propose that evidence rating schemes are formally modified so research with conflict of interest bias is explicitly downgraded in value.
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              Use of psychotropic medication in children and adolescents with autism spectrum disorders.

              The goal of this study was to examine rates of psychotropic medication use and identify associated child and family characteristics among children and adolescents with autism spectrum disorder (ASD) enrolled in an autism registry maintained by the Autism Treatment Network (ATN).
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                Author and article information

                Contributors
                +44 (0)20 3228 8553 , johnny.downs@kcl.ac.uk
                Journal
                Eur Child Adolesc Psychiatry
                Eur Child Adolesc Psychiatry
                European Child & Adolescent Psychiatry
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                1018-8827
                1435-165X
                15 October 2015
                15 October 2015
                2016
                : 25
                : 649-658
                Affiliations
                [ ]Institute of Psychiatry, Psychology and Neuroscience, King’s College London, De Crespigny Park, Box 63, SE5 8AF London, UK
                [ ]South London and Maudsley NHS Foundation Trust, London, UK
                [ ]University of Exeter Medical School, Exeter, UK
                Article
                780
                10.1007/s00787-015-0780-7
                4889626
                26472118
                e409a710-b9e4-4f13-abbf-2a7ccc65490a
                © The Author(s) 2015

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                : 1 May 2015
                : 28 September 2015
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100000265, Medical Research Council;
                Award ID: MR/L017105/1
                Award ID: MR/J01219X/1
                Award Recipient :
                Categories
                Original Contribution
                Custom metadata
                © Springer-Verlag Berlin Heidelberg 2016

                Clinical Psychology & Psychiatry
                child and adolescence,autism spectrum disorders,antipsychotic medications,psychiatric comorbidity,challenging behaviours

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