Prescribing Practices
Treatment Recommendations for the Use of Antipsychotics for Aggressive Youth
(TRAAY)
Psychiatric medications are widely used as part of the treatment for aggressive/assaultive behavior in both adults and children (Schur et al, 2003). However, there is limited scientific evidence supporting this clinical practice specifically with children (Schur et al, 2003). Atypical antipsychotic medications, in particular, are increasingly being used for this purpose in the New York State Office of Mental Health (OMH) state-operated inpatient child and adolescent facilities. In response to this concern, experts have been creating TRAAY (Treatment Recommendations for the use of Antipsychotics for Aggressive Youth) to decrease the overuse of antipsychotic medications with young people (Pappadopulos et al, 2003).
The project is a unique collaboration between the OMH Bureau of Children's Psychiatric Center Management (BCPCM), the OMH Bureau of Children and Families (BCF), the OMH Center for Information Technology and Evaluation Research (CITER) and Columbia University/Center for the Advancement of Children's Mental Health (CACMH).
The purpose of TRAAY is to carefully examine the use of antipsychotic medications with children and adolescents in OMH state-operated programs (inpatient and day treatment) who are aggressive/assaultive. Another reason for TRAAY is to develop treatment recommendations based on the existing evidence-base for using antipsychotic medications with young people who could benefit from them.
Focus groups with psychiatrists, other physicians and clinicians from all the Children's Psychiatric Centers (CPC's) and the Children and Youth Units (C&Y Units) in Psychiatric Centers were conducted to gather information on how clinicians were assessing and treating aggressive and assaultive behavior (including the use of psychiatric medications). As a result of the focus groups, a survey instrument was developed and administered to assess psychiatrist attitudes and practices with regard to assessing, treating and managing aggressive behavior (including use of psychiatric medications). Randomly selected discharged case records were also reviewed to examine the actual use of medications, particularly antipsychotic medications (Pappadopulos et al, 2002).
An expert consensus workshop of national experts and researchers was conducted that focused on psychopharmacologic treatment of aggressive/assaultive behavior. Initial consensus was reached on essential principles and recommendations for the draft treatment guidelines. A set of treatment recommendations is under development at OMH for assessing and treating aggressive behavior in children and adolescents with complex clinical presentations.
Family, Youth, Cultural PerspectivesThe development of the descriptions for each OMH Priority Set for Evidence-Based Practices included extensive involvement from clinical experts, mental health recipients, youth and family members, and people who represent culturally diverse viewpoints. Their perspectives are critical to the understanding of these important practices and programs in mental health.
Family Perspective
A separate "Parent Guide to Inpatient Treatment" is being developed in partnership with parents as part of the psychosocial intervention offered to parents of hospitalized children and adolescents.
Youth Perspective
The "Choice Thru Voice" project
was designed to increase communication between young people and the professionals
that are serving them. It was developed by youth recipients (OMH Youth Advisory
Council) for use in OMH child and adolescent inpatient and community settings.
This booklet includes questions to youth concerning their attitudes and preferences
about medications.
It is important to include the youth's perspective in medication decisions.
Importantly, treatment teams need to consider the previous trials of medications,
side effects, purposes for medication usage, why it is needed to help them function
more effectively, and awareness that the youth is not overmedicated/undermedicated.
Further, if medication does not assist in relieving symptoms, professionals
need to be willing to consider all alternatives with the youth. The focus should
be on the root and issue of the problem that is causing the illness and teaching
the youth to manage the symptoms/issues and be in control.
Cultural Perspective
The TRAAY project is committed
to considering cultural and ethnic variables, which can affect a child, adolescent
and parent's compliance with and understanding of psychiatric medications as
part of treatment.
Prescribing physicians need to demonstrate an appreciation and understanding
of the wide array of family constellations and healing practices in addition
to cultural knowledge about family norms and values around help seeking, secrecy
and confidentiality, family roles, child rearing and spiritual practices. An
ethnopsychopharmacological approach, considering the full spectrum of a child's
and families lives (i.e. diet, age and metabolism differences) will contribute
to appropriateness in diagnosis and in medication prescription. The impact of
the use of traditional and culturally specific healing needs to be taken into
account.
The TRAAY Treatment Recommendations reflect a comprehensive and systematic approach to diagnosing, assessing and treating children and adolescents who present with aggressive behavior.
The TRAAY Treatment Recommendations support the following principles: completing a diagnostic assessment before using medications; treatment of co-existing or primary psychiatric disorders before treating aggression; using psychosocial treatment interventions with the child and family before using medications; using a conservative dosing strategy with medications; carefully monitoring side effects and effectiveness of medication; minimizing use of STAT or PRN medications for managing acute aggression.
Implementing TRAAY in New York StateA four year National Institute of Mental Health (NIMH) funded study ("A Theory-Based Intervention to Change Physician Behavior") is currently testing the impact and benefits of a basic behavioral and cognitive science guided intervention ("mental contrasting-implementation intentions") on physicians behaviors related to their assessment, monitoring and use of antipsychotic medications with youth who are severely aggressive. (Jensen, P., PI)
OMH Monograph and MaterialsA comprehensive monograph, Treatment Recommendations for the Use of Antipsychotics for Aggressive Youth (TRAAY), is under development and intended to be used for training and supervision in OMH state-operated child and adolescent programs. TRAAY Treatment Recommendations have been published in the Journal of American Academy of Child and Adolescent Psychiatry (Schur et al, 2003, Pappadopulos et al, 2003).
A separate "Parent Guide to Inpatient Treatment" is being developed in partnership with parents as part of the psychosocial intervention offered to parents of hospitalized children and adolescents.
The "Choice Thru Voice" project was designed to increase communication between young people and the professionals that are serving them. It was developed by youth recipients (OMH Youth Advisory Council) for use in OMH child and adolescent inpatient and community settings. This booklet includes questions to youth concerning their attitudes and preferences about medications.
Measuring and Defining QualityA series of quality indicators with measures and standards have been developed to facilitate collection of data concerning the use of the TRAAY Treatment Recommendations
Children and Adolescent Service System Principles
All OMH Children's Initiatives are based upon the principles of the Child and Adolescent Service System Principles (CASSP). View the CASSP.
Pappadopulos, E., Jensen, P.S., Schur, S.B., MacIntyre, J.C., II, Ketner, S., Van Orden, K., Sverd, J., Sardana, S., Woodlock, D., Schweitzer, R., Rube, D. (2002) "Real world" atypical antipsychotic prescribing practices in public child and adolescent inpatient settings. Schizophrenia Bulletin, 28 (1), 111-121.
Pappadopulos, E., MacIntyre, J.C., II, Crismon, M.L., Findling, R.L., Malone, R.P., Derivan, A., Schooler, N., Sikich, L., Greenhill, L., Schur, S., Kranzler, H., Carpinello, S., Felton, C., Sverd, J., Finnerty, M., Ketner, S., Jensen, P. (2003). Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY) part two. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 145-161.
Schur, S., Sikich, L., Findling, R., Malone, R., Crismon, M., Derivan, A., MacIntyre, J., Pappadopulos, E., Greenhill, L., Schooler, N., Van Orden, K., Jensen, P. (2003) Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY) part one: Review of relevant literature. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 132-144.