Preliminary Assessment of a Novel Continuum-of-Care Model for Young People With Autism Spectrum Disorders.

Because of limited intermediate-care services, patients with autism spectrum disorders (ASDs) are increasingly being treated in emergency departments (EDs) and psychiatric hospitals. To address this growing problem, the authors developed a mobile outreach program, called Access to Psychiatry through Intermediate Care (APIC), for young (≤26 years) patients with ASD at risk for involvement with emergency medical services or the legal system. In its initial year, the average program duration per patient was 264.5 days. Clinical and Family Distress Scale scores indicated significant improvements for participating patients and caretakers. In the first year, among 40 patients with sufficient data for comparison, 13 (33%) went to the ED, and lengths of stay decreased up to 77% from pre- to postintervention. Given a cost per APIC-enrolled patient of $1,700, the net saving for the cost of ED treatment was $2,260-$2,559 per patient. The feasibility and cost-effectiveness of the APIC model has attracted additional state and county funding.

The efficacy and tolerability of methylphenidate and behavior modification in children with attention-deficit/hyperactivity disorder and severe mood dysregulation.

OBJECTIVES: This study examines the tolerability and efficacy of methylphenidate (MPH) and behavior modification therapy (BMOD) in children with attention-deficity/hyperactivity disorder (ADHD) and severe mood dysregulation (SMD). METHODS: Children (ages 5-12) from a summer program for ADHD were screened for SMD and additional manic-like symptoms using structured assessments and direct clinical interview with the Young Mania Rating Scale (YMRS). The SMD group was comprised of 33 subjects with SMD and elevated YMRS scores (mean = 23.7). They underwent weekly mood assessments plus the daily ADHD measures that are part of the program. The comparison group (n = 68) was comprised of the rest of the program participants. Using a crossover design, all subjects in both groups were treated with three varying intensities of BMOD (no, low, high) each lasting 3 weeks, with MPH dose (placebo, 0.15 mg/kg t.i.d., 0.3mg/kg t.i.d., and 0.6 mg/kg t.i.d.) varying daily within each behavioral treatment. RESULTS: Groups had comparable ADHD symptoms at baseline, with the SMD group manifesting more oppositional defiant disorder/conduct disorder (ODD/CD) symptoms (p < 0.001). Both groups showed robust improvement in externalizing symptoms (p < 0.001). There was no evidence of differential treatment efficacy or tolerability. Treatment produced a 34% reduction in YMRS ratings in SMD subjects (p - 0.001). However, they still exhibited elevated YMRS ratings, more ODD/CD symptoms (p < 0.001), and were more likely to remain significantly impaired at home than non-SMD subjects (p < 0.05). CONCLUSIONS: MPH and BMOD are tolerable and effective treatments for children with ADHD and SMD, but additional treatments may be needed to optimize their functioning.

Pharmacologic management of behavioral instability in medically ill pediatric patients.

PURPOSE OF REVIEW: Behavioral instability in children and adolescents is a vexing problem faced by many clinicians. This dilemma is magnified when it presents in a child with an acute medical condition. Effective treatment in these cases with medications may help to reduce morbidity and facilitate appropriate medical care for the underlying condition. RECENT FINDINGS: There are many reviews, but few studies examine the treatment of behavioral instability in the pediatric population. There are even fewer that address behavioral instability in the presence of a comorbid medical condition. Many effective agents may worsen a given condition or interfere with the treatment of that condition. There are no prospective studies addressing this issue. SUMMARY: Many psychotropic medications must be considered when treating behavioral instability in medically ill children. Antihistamines, benzodiazepines, and antipsychotics may be of particular benefit. Definitive research is lacking and necessary to develop appropriate clinical guidelines. This article considers the most current literature and provides an overall summary of the topic.