497537 2013
AUT18610.1177/1362361313497537AutismSchubart et al.
Original Article
Psychotropic medication trends among children and adolescents with autism spectrum disorder in the Medicaid program
Autism 2014, Vol. 18(6) 631–637 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1362361313497537 aut.sagepub.com
Jane R Schubart, Fabian Camacho and Douglas Leslie
Abstract This study characterized psychotropic medication use among Medicaid-enrolled children and adolescents with autism spectrum disorders by examining trends over time, including length of treatment and polypharmacy using 4 years of administrative claims data from 41 state Medicaid programs (2000–2003). The data set included nearly 3 million children and adolescents who were 17 years or younger. Approximately, 65% of children with autism spectrum disorder received a psychotropic medication. The results indicate an increasing overall trend in the use of psychotropic drugs among children and adolescents with autism spectrum disorders. Among the different classes of psychotropic drugs, antipsychotics were the most common. Increasing trends in polypharmacy were observed both within and between medication classes. Keywords autism spectrum disorder, children and adolescents, Medicaid, psychotropic medications
Introduction Background Research about the use of psychotropic medications to control symptoms of autism spectrum disorders (ASD) in children is limited and conflicting for some drug classes (Gerhard et al., 2009; Mandell et al., 2008; Morgan and Taylor, 2007). Treatment of children with ASD often includes these medications to target symptoms that affect daily life, such as aggression, hyperactivity, anxiety, sleep problems, and self-injurious behavior (Gringras, 2000; Myers and Johnson, 2007; Rosenberg et al., 2010; Towbin, 2003). Although only risperidone and aripiprazole (both atypical antipsychotics) have been approved by the Food and Drug Administration for treatment of aggression and irritability in ASD, many medications are commonly prescribed (Ching and Pringshei, 2012; McCracken et al., 2002; Posey et al., 2008). Previous studies have reported that 30%–60% of children with ASD use at least one psychotropic medication, and use of these drugs seems to be increasing over time. Aman et al. (1995) reported that the prevalence of psychotropic medication use among children with ASD in 1995 was 30%, and in a follow-up study in 2001, the authors reported an increase to 44% (Aman et al., 2003). In a 2001 cross-sectional study, Mandell et al. (2008)
examined the point prevalence of psychotropic medication use among 60,641 Medicaid claimants less than 21 years of age and found that 56% were prescribed at least one psychotropic medication and 20% were prescribed three or more concurrently. Use in children aged 0–2 years was 18%, and 3–5 years was 32%. Importantly, this study showed that factors not related to clinical presentation were highly correlated with prescribing practice, including socioeconomic and health system factors. Children whose Medicaid eligibility was based on disability were more likely to receive psychotropic medications than those who were eligible because of poverty. A related study using the same data set, but restricted to children aged 3–18 years, reports the prevalence of psychotropic medication use being especially high among children in foster care (20.8% The Pennsylvania State University, USA Corresponding author: Jane R Schubart, Department of Surgery, Medicine, & Public Health Sciences, College of Medicine, The Pennsylvania State University, 500 University Drive, Hershey, PA 17033, USA. Email: [email protected]
Downloaded from aut.sagepub.com at GEORGIAN COURT UNIV on April 2, 2015
632
Autism 18(6)
used three or more classes of medication) with state-level differences observed, suggesting that policy or program differences might affect prescribing (Rubin et al., 2009). Several other studies have looked at use of psychotropic medications in children. Using Internet-based questionnaire data collected in 2007–2008 for 5181 individuals with ASD who were 18 years or younger, Rosenberg et al. (2010) found that 35% currently used at least one psychotropic medication and nearly 10% reported concurrent use in three or more major classes (Rosenberg et al., 2010). In a cross-sectional analysis of 2007 Medicaid fee-for-service claims data for Mississippi, Khanna et al. (2012) found that 66% had a claim for a psychotropic drug during the year, with antipsychotics being the most commonly used and the highest cost per claim (Khanna et al., 2012). Although there are fewer studies that focus on adolescents with ASD, Esbensen et al. (2009) analyzed medication data from a larger longitudinal study of adolescents and adults with ASD living in Wisconsin and Massachusetts (Esbensen et al., 2009). The authors compared data collected during home interviews in two time periods (1998–2000 and 2004–2005) and found that individuals taking any prescription medications rarely discontinued use of the medication over a 4.5-year period; in fact, for psychotropic medications, the likelihood of staying medicated was 11 times the likelihood of discontinuing medication. In contrast to previous studies that have examined rates of psychotropic medication use, this study further characterized psychotropic medication use in children and adolescents with ASD by examining use over time, compared to a control group of children without ASD, including length of treatment and concurrent use of multiple medications.
Methods Source of data Medicaid Analytic eXtract (MAX) data from 41 states for 2000–2003 were used for the study. The MAX files, developed by the Centers for Medicare & Medicaid Services (CMS), provide administrative claims data to support research on Medicaid populations. MAX files provide person-level data and include information on Medicaid eligibility, service utilization, and payments. They are organized into four claims files (Inpatient, Other Therapy, Long-Term Care, and Prescription Drug) and a Personal Summary File that contains enrollment information. This study included the District of Columbia and all except the following 10 states: Colorado, Delaware, Michigan, Montana, North Dakota, South Dakota, Tennessee, Utah, Washington, and Ohio. Ohio was excluded because the “day supply” data were missing. The other 9 states were excluded due to the high degree of managed care penetration during the study period. The data set included nearly 3 million children and adolescents who were 17 years or younger on 1 January of each study year.
Measures First, for each study year, all Medicaid patients who were continuously enrolled for the entire year in a fee-for-service plan were identified. The ASD sample included patients who had either two outpatient visits or one inpatient visit with a diagnosis of ASD. ASD was defined as International Classification of Diseases, Ninth Revision (ICD-9) codes 299.0x (autistic disorder), 299.1x (childhood disintegrative disorder), or 299.8x (other specified pervasive developmental disorders). The final ASD study sample included 13,390 patients in 2000 with a diagnosis of ASD; 15,805 in 2001; 16,818 in 2002; and 19,243 in 2003. A non-ASD comparison group was identified that included individuals with any mental health disorders (ICD-9 codes in the 290. xx to 319.xx range, and NOT 299.xx (psychoses with origin specific to childhood), 305.1x (nondependent tobacco use disorder), 310.xx or 331.xx (specific nonpsychotic mental disorders following organic brain damage; hereditary and degenerative diseases of CNS)). For these patients, all prescriptions for psychotropic medications were identified and classified by national drug code into the following classes: antidepressants (SSRIs, SNRIs, tricyclics, etc.), neuroleptics (both first and second generation), anxiolytics (chlordiazepoxide, diazepam, clonazepam, etc.), mood stabilizers (lithium, valproic acid, etc.), sedative/hypnotics (diphenhydramine, promethazine, etc.), and stimulants (methylphenidate, dextroamphetamine, etc.). A number of variables describing psychotropic medication use were constructed, including receipt of any medication, length of therapy, and polypharmacy. “Use” of medication was defined as the presence of a claim for a psychotropic medication prescription in the MAX data set. Length of therapy was defined as consecutive days of use within a study year; thus, the maximum was 365 days since each study year was examined separately. Polypharmacy was defined in two different ways: first, as concurrent use of psychotropic medications in different classes of medication (between-class), and second as concurrent use of multiple medications within any single class (within-class), with concurrent use defined as use of two or more medications overlapping for at least 60 days. We also show data for 30-day concurrent use. Demographic characteristics were obtained from the Medicaid eligibility file and included gender, age, race/ ethnicity (White, Black, Hispanic, other, and unknown), Medicaid eligibility status (disabled, poverty, foster, and other), and census region.
Analysis The number and proportion of psychotropic medication users were calculated by type of medication in the ASD sample and in the non-ASD comparison group. For both groups, length of treatment was determined. Variables describing psychotropic medication usage over the study period, 2000–2003, were examined, by class of medication,
Downloaded from aut.sagepub.com at GEORGIAN COURT UNIV on April 2, 2015
633
Schubart et al. Table 1. Characteristics of the sample. Characteristics Number of enrollees age ⩽ 17 Number of patients with ASD Gender Male Female Age 3−5 years 6−11 years 12−17 years Ethnicity/race White Black Hispanic Other Unknown Eligibility Disabled Poverty Foster Other Census Region Midwest Northeast South West
2000
2001
2002
2003
2,126,498 12,843
2,275,630 15,214
2,271,850 16,197
2,271,490 18,562
10,080 (78%) 2763 (22%)
12,057 (79%) 3157 (21%)
12,833 (79%) 3364 (21%)
14,706 (79%) 3855 (21%)
2893 (23%) 6640 (52%) 3310 (25%)
3177 (21%) 7736 (51%) 4301 (28%)
3294 (20%) 8105 (50%) 4798 (30%)
3772 (20%) 9049 (49%) 5741 (31%)
6465 (50%) 2354 (18%) 921 (7%) 304 (2%) 2799 (22%)
7801 (51%) 2675 (18%) 1064 (7%) 403 (3%) 3271 (21%)
8547 (53%) 2623 (16%) 1197 (7%) 313 (2%) 3517 (22%)
10,002 (54%) 2830 (15%) 1404 (8%) 384 (2%) 3942 (21%)
9633 (75%) 1334 (10%) 1175 (9%) 701 (5%)
11,480 (75%) 1684 (11%) 1384 (9%) 666 (4%)
11,895 (73%) 1790 (12%) 1518 (9%) 994 (6%)
13,131 (71%) 2665 (14%) 1690 (9%) 1076 (6%)
3239 (25%) 3938 (31%) 4252 (33%) 1414 (11%)
3780 (25%) 4471 (29%) 5167 (34%) 1796 (12%)
4405 (27%) 4730 (29%) 4962 (31%) 2100 (13%)
5304 (29%) 5453 (29%) 5709 (31%) 2096 (11%)
age, race, and Medicaid eligibility. Psychotropic polypharmacy was examined, both within classes of medication and across multiple classes. Data were analyzed using SAS version 9.2 (SAS Institute, Cary, NC).
Results In our sample of approximately 2.2 million Medicaid enrollees, aged 3–17 years, we identified between 12,843 and 18,562 individuals with ASD per year and between 222,704 and 267,234 individuals in the control group. The ASD sample was mostly male (78%–79%), White (50%– 54%), and eligible for Medicaid services due to disability (71%–75%), although those eligible due to poverty increased over the time period and disability decreased. Approximately half of the children in the ASD sample were 6–11 years old, and 25%–31% were 12–17 years old. Relatively few children with ASD in our sample were from the west (11%–13%), reflecting the higher managed care population (Table 1). We found that approximately 65% of children with ASD received a psychotropic medication (Table 2). Antipsychotic medications were the most common (39% in 2003), followed by antidepressants (29%), stimulants (25%), mood stabilizers (16%), sedative/hypnotics (14%), and anxiolytics (11%). Smaller percentages (from 54.3%
to 57.0%) of patients in the control group received any psychotropic drug. The largest difference in psychotropic medication use between the ASD and comparison groups was in the antipsychotic class, where an average of 36.9% of ASD patients received these drugs compared to 13.7% of the comparison group. Smaller percentages of individuals in the ASD group received stimulants compared to the comparison group. An increasing trend was observed in the use of antidepressant and antipsychotic medications among the ASD group over the 4-year period, although the rate of increase was higher in the comparison group. We found a steady increase in length of treatment (days) in the antidepressant, antipsychotics, mood stabilizer, and sedative/hypnotics categories among children and adolescents with ASD (Table 2). Children with ASD had longer mean length of treatment in all categories compared to children with other mental health diagnoses. Table 3 shows the breakdown of length of treatment by age group. Length of treatment for antipsychotic medications increased from 2000–2003 in age 3–5 years (from 173 to 194.5 median days), in age 6–11 years (from 232 to 263 median days), and in age 12–17 years (from 264 to 290 median days). An increasing trend from 2000 to 2003 was observed for use of antipsychotics in all age groups and for the use of antidepressants and mood stabilizers for both the 6–11 and the
Downloaded from aut.sagepub.com at GEORGIAN COURT UNIV on April 2, 2015
222,704 (54.3) 9783 (64.3) 82,996 (20.2) 4311 (28.3) 150.0 (104.2) 194.5 (112.6) 47,449 (11.5) 5482 (36.0) 165.9 (109.2) 221.3 (106.2) 19,435 (4.7) 1795 (11.8) 112.5 (109.4) 128.0 (122.8) 34,508 (8.4) 2484 (16.3) 177.9 (111.8) 212.3 (112.9) 57,382 (14.0) 2391 (15.7) 24.52 (48.9) 45.66 (79.71) 130,208 (31.7) 3928 (25.8) 172.5 (97.14) 192.3 (109.6)
8212 (63.9)
3495 (27.2) 187.3 (111.5)
4328 (33.7) 213.2 (107.1)
1493 (11.6) 124.3 (118.9)
2116 (16.5) 206.4 (112.0)
2073 (16.1) 43.93 (78.21)
3201 (24.9) 186.6 (108.9)
Downloaded from aut.sagepub.com at GEORGIAN COURT UNIV on April 2, 2015
LOT: length of treatment (in days). *All p-values for chi-square test for differences between ASD and Control
AUT18610.1177/1362361313497537AutismSchubart et al.
Original Article
Psychotropic medication trends among children and adolescents with autism spectrum disorder in the Medicaid program
Autism 2014, Vol. 18(6) 631–637 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1362361313497537 aut.sagepub.com
Jane R Schubart, Fabian Camacho and Douglas Leslie
Abstract This study characterized psychotropic medication use among Medicaid-enrolled children and adolescents with autism spectrum disorders by examining trends over time, including length of treatment and polypharmacy using 4 years of administrative claims data from 41 state Medicaid programs (2000–2003). The data set included nearly 3 million children and adolescents who were 17 years or younger. Approximately, 65% of children with autism spectrum disorder received a psychotropic medication. The results indicate an increasing overall trend in the use of psychotropic drugs among children and adolescents with autism spectrum disorders. Among the different classes of psychotropic drugs, antipsychotics were the most common. Increasing trends in polypharmacy were observed both within and between medication classes. Keywords autism spectrum disorder, children and adolescents, Medicaid, psychotropic medications
Introduction Background Research about the use of psychotropic medications to control symptoms of autism spectrum disorders (ASD) in children is limited and conflicting for some drug classes (Gerhard et al., 2009; Mandell et al., 2008; Morgan and Taylor, 2007). Treatment of children with ASD often includes these medications to target symptoms that affect daily life, such as aggression, hyperactivity, anxiety, sleep problems, and self-injurious behavior (Gringras, 2000; Myers and Johnson, 2007; Rosenberg et al., 2010; Towbin, 2003). Although only risperidone and aripiprazole (both atypical antipsychotics) have been approved by the Food and Drug Administration for treatment of aggression and irritability in ASD, many medications are commonly prescribed (Ching and Pringshei, 2012; McCracken et al., 2002; Posey et al., 2008). Previous studies have reported that 30%–60% of children with ASD use at least one psychotropic medication, and use of these drugs seems to be increasing over time. Aman et al. (1995) reported that the prevalence of psychotropic medication use among children with ASD in 1995 was 30%, and in a follow-up study in 2001, the authors reported an increase to 44% (Aman et al., 2003). In a 2001 cross-sectional study, Mandell et al. (2008)
examined the point prevalence of psychotropic medication use among 60,641 Medicaid claimants less than 21 years of age and found that 56% were prescribed at least one psychotropic medication and 20% were prescribed three or more concurrently. Use in children aged 0–2 years was 18%, and 3–5 years was 32%. Importantly, this study showed that factors not related to clinical presentation were highly correlated with prescribing practice, including socioeconomic and health system factors. Children whose Medicaid eligibility was based on disability were more likely to receive psychotropic medications than those who were eligible because of poverty. A related study using the same data set, but restricted to children aged 3–18 years, reports the prevalence of psychotropic medication use being especially high among children in foster care (20.8% The Pennsylvania State University, USA Corresponding author: Jane R Schubart, Department of Surgery, Medicine, & Public Health Sciences, College of Medicine, The Pennsylvania State University, 500 University Drive, Hershey, PA 17033, USA. Email: [email protected]
Downloaded from aut.sagepub.com at GEORGIAN COURT UNIV on April 2, 2015
632
Autism 18(6)
used three or more classes of medication) with state-level differences observed, suggesting that policy or program differences might affect prescribing (Rubin et al., 2009). Several other studies have looked at use of psychotropic medications in children. Using Internet-based questionnaire data collected in 2007–2008 for 5181 individuals with ASD who were 18 years or younger, Rosenberg et al. (2010) found that 35% currently used at least one psychotropic medication and nearly 10% reported concurrent use in three or more major classes (Rosenberg et al., 2010). In a cross-sectional analysis of 2007 Medicaid fee-for-service claims data for Mississippi, Khanna et al. (2012) found that 66% had a claim for a psychotropic drug during the year, with antipsychotics being the most commonly used and the highest cost per claim (Khanna et al., 2012). Although there are fewer studies that focus on adolescents with ASD, Esbensen et al. (2009) analyzed medication data from a larger longitudinal study of adolescents and adults with ASD living in Wisconsin and Massachusetts (Esbensen et al., 2009). The authors compared data collected during home interviews in two time periods (1998–2000 and 2004–2005) and found that individuals taking any prescription medications rarely discontinued use of the medication over a 4.5-year period; in fact, for psychotropic medications, the likelihood of staying medicated was 11 times the likelihood of discontinuing medication. In contrast to previous studies that have examined rates of psychotropic medication use, this study further characterized psychotropic medication use in children and adolescents with ASD by examining use over time, compared to a control group of children without ASD, including length of treatment and concurrent use of multiple medications.
Methods Source of data Medicaid Analytic eXtract (MAX) data from 41 states for 2000–2003 were used for the study. The MAX files, developed by the Centers for Medicare & Medicaid Services (CMS), provide administrative claims data to support research on Medicaid populations. MAX files provide person-level data and include information on Medicaid eligibility, service utilization, and payments. They are organized into four claims files (Inpatient, Other Therapy, Long-Term Care, and Prescription Drug) and a Personal Summary File that contains enrollment information. This study included the District of Columbia and all except the following 10 states: Colorado, Delaware, Michigan, Montana, North Dakota, South Dakota, Tennessee, Utah, Washington, and Ohio. Ohio was excluded because the “day supply” data were missing. The other 9 states were excluded due to the high degree of managed care penetration during the study period. The data set included nearly 3 million children and adolescents who were 17 years or younger on 1 January of each study year.
Measures First, for each study year, all Medicaid patients who were continuously enrolled for the entire year in a fee-for-service plan were identified. The ASD sample included patients who had either two outpatient visits or one inpatient visit with a diagnosis of ASD. ASD was defined as International Classification of Diseases, Ninth Revision (ICD-9) codes 299.0x (autistic disorder), 299.1x (childhood disintegrative disorder), or 299.8x (other specified pervasive developmental disorders). The final ASD study sample included 13,390 patients in 2000 with a diagnosis of ASD; 15,805 in 2001; 16,818 in 2002; and 19,243 in 2003. A non-ASD comparison group was identified that included individuals with any mental health disorders (ICD-9 codes in the 290. xx to 319.xx range, and NOT 299.xx (psychoses with origin specific to childhood), 305.1x (nondependent tobacco use disorder), 310.xx or 331.xx (specific nonpsychotic mental disorders following organic brain damage; hereditary and degenerative diseases of CNS)). For these patients, all prescriptions for psychotropic medications were identified and classified by national drug code into the following classes: antidepressants (SSRIs, SNRIs, tricyclics, etc.), neuroleptics (both first and second generation), anxiolytics (chlordiazepoxide, diazepam, clonazepam, etc.), mood stabilizers (lithium, valproic acid, etc.), sedative/hypnotics (diphenhydramine, promethazine, etc.), and stimulants (methylphenidate, dextroamphetamine, etc.). A number of variables describing psychotropic medication use were constructed, including receipt of any medication, length of therapy, and polypharmacy. “Use” of medication was defined as the presence of a claim for a psychotropic medication prescription in the MAX data set. Length of therapy was defined as consecutive days of use within a study year; thus, the maximum was 365 days since each study year was examined separately. Polypharmacy was defined in two different ways: first, as concurrent use of psychotropic medications in different classes of medication (between-class), and second as concurrent use of multiple medications within any single class (within-class), with concurrent use defined as use of two or more medications overlapping for at least 60 days. We also show data for 30-day concurrent use. Demographic characteristics were obtained from the Medicaid eligibility file and included gender, age, race/ ethnicity (White, Black, Hispanic, other, and unknown), Medicaid eligibility status (disabled, poverty, foster, and other), and census region.
Analysis The number and proportion of psychotropic medication users were calculated by type of medication in the ASD sample and in the non-ASD comparison group. For both groups, length of treatment was determined. Variables describing psychotropic medication usage over the study period, 2000–2003, were examined, by class of medication,
Downloaded from aut.sagepub.com at GEORGIAN COURT UNIV on April 2, 2015
633
Schubart et al. Table 1. Characteristics of the sample. Characteristics Number of enrollees age ⩽ 17 Number of patients with ASD Gender Male Female Age 3−5 years 6−11 years 12−17 years Ethnicity/race White Black Hispanic Other Unknown Eligibility Disabled Poverty Foster Other Census Region Midwest Northeast South West
2000
2001
2002
2003
2,126,498 12,843
2,275,630 15,214
2,271,850 16,197
2,271,490 18,562
10,080 (78%) 2763 (22%)
12,057 (79%) 3157 (21%)
12,833 (79%) 3364 (21%)
14,706 (79%) 3855 (21%)
2893 (23%) 6640 (52%) 3310 (25%)
3177 (21%) 7736 (51%) 4301 (28%)
3294 (20%) 8105 (50%) 4798 (30%)
3772 (20%) 9049 (49%) 5741 (31%)
6465 (50%) 2354 (18%) 921 (7%) 304 (2%) 2799 (22%)
7801 (51%) 2675 (18%) 1064 (7%) 403 (3%) 3271 (21%)
8547 (53%) 2623 (16%) 1197 (7%) 313 (2%) 3517 (22%)
10,002 (54%) 2830 (15%) 1404 (8%) 384 (2%) 3942 (21%)
9633 (75%) 1334 (10%) 1175 (9%) 701 (5%)
11,480 (75%) 1684 (11%) 1384 (9%) 666 (4%)
11,895 (73%) 1790 (12%) 1518 (9%) 994 (6%)
13,131 (71%) 2665 (14%) 1690 (9%) 1076 (6%)
3239 (25%) 3938 (31%) 4252 (33%) 1414 (11%)
3780 (25%) 4471 (29%) 5167 (34%) 1796 (12%)
4405 (27%) 4730 (29%) 4962 (31%) 2100 (13%)
5304 (29%) 5453 (29%) 5709 (31%) 2096 (11%)
age, race, and Medicaid eligibility. Psychotropic polypharmacy was examined, both within classes of medication and across multiple classes. Data were analyzed using SAS version 9.2 (SAS Institute, Cary, NC).
Results In our sample of approximately 2.2 million Medicaid enrollees, aged 3–17 years, we identified between 12,843 and 18,562 individuals with ASD per year and between 222,704 and 267,234 individuals in the control group. The ASD sample was mostly male (78%–79%), White (50%– 54%), and eligible for Medicaid services due to disability (71%–75%), although those eligible due to poverty increased over the time period and disability decreased. Approximately half of the children in the ASD sample were 6–11 years old, and 25%–31% were 12–17 years old. Relatively few children with ASD in our sample were from the west (11%–13%), reflecting the higher managed care population (Table 1). We found that approximately 65% of children with ASD received a psychotropic medication (Table 2). Antipsychotic medications were the most common (39% in 2003), followed by antidepressants (29%), stimulants (25%), mood stabilizers (16%), sedative/hypnotics (14%), and anxiolytics (11%). Smaller percentages (from 54.3%
to 57.0%) of patients in the control group received any psychotropic drug. The largest difference in psychotropic medication use between the ASD and comparison groups was in the antipsychotic class, where an average of 36.9% of ASD patients received these drugs compared to 13.7% of the comparison group. Smaller percentages of individuals in the ASD group received stimulants compared to the comparison group. An increasing trend was observed in the use of antidepressant and antipsychotic medications among the ASD group over the 4-year period, although the rate of increase was higher in the comparison group. We found a steady increase in length of treatment (days) in the antidepressant, antipsychotics, mood stabilizer, and sedative/hypnotics categories among children and adolescents with ASD (Table 2). Children with ASD had longer mean length of treatment in all categories compared to children with other mental health diagnoses. Table 3 shows the breakdown of length of treatment by age group. Length of treatment for antipsychotic medications increased from 2000–2003 in age 3–5 years (from 173 to 194.5 median days), in age 6–11 years (from 232 to 263 median days), and in age 12–17 years (from 264 to 290 median days). An increasing trend from 2000 to 2003 was observed for use of antipsychotics in all age groups and for the use of antidepressants and mood stabilizers for both the 6–11 and the
Downloaded from aut.sagepub.com at GEORGIAN COURT UNIV on April 2, 2015
222,704 (54.3) 9783 (64.3) 82,996 (20.2) 4311 (28.3) 150.0 (104.2) 194.5 (112.6) 47,449 (11.5) 5482 (36.0) 165.9 (109.2) 221.3 (106.2) 19,435 (4.7) 1795 (11.8) 112.5 (109.4) 128.0 (122.8) 34,508 (8.4) 2484 (16.3) 177.9 (111.8) 212.3 (112.9) 57,382 (14.0) 2391 (15.7) 24.52 (48.9) 45.66 (79.71) 130,208 (31.7) 3928 (25.8) 172.5 (97.14) 192.3 (109.6)
8212 (63.9)
3495 (27.2) 187.3 (111.5)
4328 (33.7) 213.2 (107.1)
1493 (11.6) 124.3 (118.9)
2116 (16.5) 206.4 (112.0)
2073 (16.1) 43.93 (78.21)
3201 (24.9) 186.6 (108.9)
Downloaded from aut.sagepub.com at GEORGIAN COURT UNIV on April 2, 2015
LOT: length of treatment (in days). *All p-values for chi-square test for differences between ASD and Control
