Psychotropic Medication Utilization Among Children Diagnosed With Fetal Alcohol Spectrum Disorder.

BACKGROUND AND OBJECTIVES: To date, there has been no large, population-based study estimating the prevalence of psychotropic medication use and cooccurring medical conditions among children with fetal alcohol syndrome disorder (FASD). In addition, it is not known how psychotropic medication use varies by mental health status of the children with FASD and their health insurance coverage. This study attempts to fill this gap by analyzing a large health insurance claims database covering Medicaid and private insurance. METHODS: The study used the 2017 IBM Watson Health MarketScan Multistate Medicaid and Commercial Claims databases. The sample for the analysis includes children between the ages of 0 and 17 with either an FASD diagnosis or a mental health diagnosis (N = 848 721 Medicaid; N = 511 061 private insurance). RESULTS: More than half of the children with an FASD diagnosis were prescribed psychotropic medications (63% Medicaid; 57% private). Utilization rates of psychotropic medication among children with cooccurring FASD and a mental health condition (79% Medicaid; 71% private) were higher compared to children with a mental health diagnosis but no FASD (57% Medicaid; 57% private). Stimulants were the most commonly prescribed. Encephalopathy, attention deficit hyperactivity disorder, and epilepsy were the 3 most common cooccurring diagnosis among children with FASD using psychotropic medication under Medicaid compared to encephalopathy, attention deficit hyperactivity disorder, and anxiety with private insurance. CONCLUSIONS: These results exemplify the complexity of the neurobehavioral profile of children with FASD and the challenge of treatment. Future studies may determine how supportive services for these children will affect psychotropic medication use.

Fetal Alcohol Research Caring for Patients with Prenatal Alcohol Exposure: A Needs Assessment.

BACKGROUND: Prenatal alcohol exposure (PAE) is the United States' most common preventable cause of birth defects and intellectual and developmental disabilities collectively referred to as Fetal Alcohol Spectrum Disorders (FASD). OBJECTIVES: This study was designed to identify gaps in pediatric providers' knowledge and practices regarding FASD patient identification, diagnosis, management and referral, and to inform needs-based FASD resource development. METHODS: Pediatric providers (pediatricians, trainees, nurse practitioners) were exposed to survey links embedded in newsletters electronically distributed to the membership of two national professional societies. Survey responses were compiled and analyzed using descriptive statistics. RESULTS: Of the 436 respondents, 71% were pediatricians and 88.2% suspected that a child in their practice could have an FASD. Only 29.2% of respondents felt "very comfortable" diagnosing or referring an individual with suspected FASD. Merely 11.5% were satisfied with their current FASD knowledge base and practice behaviour. Most respondents (89.6%) indicated online continuing education courses as preferred learning method and suggested their knowledge and practices would be best enhanced through FASD-specific diagnostic and referral checklists or algorithms, and patient education brochures and fact sheets. CONCLUSIONS: This study showed that few respondents were satisfied with their current FASD knowledge or practice behaviours. Continuing FASD education, particularly through online courses, was strongly desired. To maximize FASD recognition and optimize care for patients with FASDs, pediatric care providers must ensure that their FASD knowledge base, practice skills and provision of medical home care remain current.

Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure.

Children and adolescents affected by prenatal exposure to alcohol who have brain damage that is manifested in functional impairments of neurocognition, self-regulation, and adaptive functioning may most appropriately be diagnosed with neurobehavioral disorder associated with prenatal exposure. This Special Article outlines clinical implications and guidelines for pediatric medical home clinicians to identify, diagnose, and refer children regarding neurobehavioral disorder associated with prenatal exposure. Emphasis is given to reported or observable behaviors that can be identified as part of care in pediatric medical homes, differential diagnosis, and potential comorbidities. In addition, brief guidance is provided on the management of affected children in the pediatric medical home. Finally, suggestions are given for obtaining prenatal history of in utero exposure to alcohol for the pediatric patient.

Attention deficit hyperactivity, fetal alcohol spectrum disorder, or something else: the broad differential of kindergarten suspension.

CASE: Thomas is a 5-year 6-month-old boy whose parents requested an urgent care appointment because he has recently been suspended from kindergarten stating "and his doctor must see him before he can come back." His suspension from kindergarten was due to kicking and biting his classmates, but he has also become increasingly aggressive at home. His teacher reported that he has always had a high activity level and difficulty shifting attention between tasks, as well as noncompliance with rules and directions. He is noted to have learning challenges and is showing difficulties in the concept of numbers and letter sounds. The practice has followed Thomas since his healthy birth. He has a history of delayed language development, and he received early intervention services from 2 years of age. He spoke his first word at 2 years 6 months. He started a half-day preschool program at 3 years of age. He had difficulty acclimating to preschool, interacting with peers, and was described as "hyperactive" by his teachers. His program was modified to decrease his time having to sit in a circle time, and he often required the support of the paraprofessional in the classroom. His parents have always described him as a "difficult child." He gets frustrated easily and can tantrum for up to 2 hours multiple times in a week when his immediate needs or requests are not met. He has difficulty falling asleep, has frequent night awakenings, and often has trouble getting back to sleep. His self-help skills are poor, and he has difficulty with activities such as brushing his teeth and dressing. His parents report that he does not seem to remember rules from day to day. He was evaluated at 5 years of age and diagnosed with Attention Deficit Hyperactivity Disorder, but his response to stimulants has been limited. Thomas is an only child. His parents are college educated and professionally employed. They deny drug use, domestic violence, and guns in the home. They reported that prior to the pregnancy, they enjoyed "partying" with friends on the weekends, but Thomas's mother reported that she stopped drinking as soon as she realized she was pregnant. All are wondering whether this child might have a fetal alcohol spectrum disorder, although he seems to have no clear facial dysmorphology. It is unsure what the next step might be and if there is value added in pursuing this diagnosis. What do you do next?

Fetal alcohol spectrum disorders: an overview for pediatric and adolescent care providers.

Fetal alcohol spectrum disorder (FASD) is a term used to describe the spectrum of conditions associated with prenatal alcohol exposure. These are characterized by facial dysmorphia, growth deficits and central nervous system abnormalities. FASDs are the most common preventable cause of intellectual disability in the United States and have high financial costs. Therefore, efforts at prevention are paramount. When an individual with an FASD goes undiagnosed and when appropriate interventions are not instituted, secondary disabilities such as substance abuse, school dropout, and criminal involvement are common with corresponding suffering endured by both the affected individual and the family. The diagnostic process opens up access to existing tools and resources, including the new American Academy of Pediatrics (AAP) FASD algorithm for the evaluation of FASDs, the new AAP FASD toolkit and evidence-based interventions specific to FASDs. Pediatric and adolescent clinicians are challenged to participate in the continuum of care from FASD prevention to identification, diagnosis, and management, including provision of supportive services for families in order for clinicians to make a difference in this 100% preventable disorder.

Screening and brief intervention for risky alcohol use.

Alcohol screening and brief intervention are effective evidence-based methods recommended by multiple major medical societies. Primary care providers are uniquely positioned to recognize patients with alcohol use problems when they utilize screening in their practices. SBI has the potential to improve patients' overall health, reduce the risk of alcohol dependence, and prevent future alcohol-exposed pregnancies.

Fetal alcohol spectrum disorders: guidance for recognition, diagnosis, differential diagnosis and referral.

FASDs are the most common preventable cause of developmental and intellectual disabilities in the United States and yet can easily be overlooked in pediatric and adolescent practices. Early diagnosis, presence of developmental and educational services, and a nurturing home environment have been associated with decreased occurrence of secondary disabilities such as substance use and criminal involvement.23 Therefore, it is important for providers to know how to go about the identification, diagnostic, and evaluation process. Pediatric care clinicians should be knowledgeable about the diagnostic criteria for fetal alcohol syndrome and know common differentiating conditions. Furthermore, they should be able to recognize other disorders on the spectrum, and in doing so, they should facilitate appropriate referral, initial management, and coordination of care.