Deprescribing psychiatric medications in youth: A feasibility study

Deprescribing psychiatric medications in youth: A feasibility study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Deprescribing psychiatric medications in youth: A feasibility study Erin R. Barnett, Jennifer L. McLaren, Hannah B. Leavitt, Stephanie C. Acquilano, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9201326/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background and objective: Rates of psychiatric medication use among U.S. youth have increased substantially and stakeholders are increasingly concerned. We tested the feasibility of a novel intervention that combines shared decision making and a structured deprescribing protocol during routine outpatient care with youth. Methods: Five clinicians delivered the intervention to youth 6 to 17 years old receiving three or more psychiatric medications or an off-label antipsychotic. Families completed assessments at baseline, 18- and 30-weeks. We collected data via surveys, medical records, and qualitative interviews. Results: We enrolled 31 youth, 29 received the intervention, and 13 of the 29 (45%) chose to deprescribe. Eleven of those 13 reduced their dose or stopped completely; 2 returned to their original dose. Of the 13, the mean dose-weighted medication use reduced from 3.9 (SD=1.38) to 2.9 (SD=1.41), and the mean number of medication reactions reduced from 1.3 (SD=2.21) to 0.3 (SD=0.48). In the 16 participants who chose not to deprescribe, the mean dose-weighted medication use and medication reactions reduced from 3.4 (SD=0.89) to 3.2 (SD=1.32) and 0.6 (SD=0.89) to 0.0 (SD=0.0), respectively. Youth functioning remained similar across groups. There were no study-related serious adverse events. Clinicians and caregivers considered the intervention feasible, valuable, and effective. Conclusions: Our intervention and procedures were feasible in real-world community settings. The intervention shows promising findings related to safety and effectiveness. Trial registration: Our study was retrospectively registered with ClinicalTrials.gov. NCT # pending. psychiatric medications children adolescents shared decision making patient decision aids deprescribing Figures Figure 1 Figure 2 Figure 3 Introduction The use of off-label antipsychotics and psychiatric polypharmacy, defined here as three or more psychiatric medications, has increased internationally and among US children and adolescents, henceforth referred to as youth, over the past 20 years.(Chiang et al., 2024; Davis et al., 2021; Winterstein et al., 2017; J. M. Zito et al., 2021) An estimated 1.3 million youth in the US receive psychiatric polypharmacy or off-label antipsychotics.(Olfson et al., 2015; J. M. Zito et al., 2021) Youth also remain on these medications far longer than the clinical durations studied.(Crystal et al., 2016; J. M. Zito et al., 2013) Youth with social and developmental vulnerabilities, including those receiving Medicaid and those in foster care, have the highest rates of off-label antipsychotic use and polypharmacy.(Allen et al., 2018; Barnett et al., 2019; Crystal et al., 2016; Dosreis et al., 2011; Simmel et al., 2021; Zuddas et al., 2011) Side effects reported for antipsychotics can include weight gain, metabolic abnormalities, neurocognitive impairments, sedation, tremor, somnolence, and restlessness.(Caccia, 2013; Cohen et al., 2012; Pillay et al., 2017; Zuddas et al., 2011) Long-term antipsychotic use in adults has given rise to obesity, diabetes, heart disease, cortical thinning, and impaired social functioning.(Andreasen et al., 2013) The recommended monitoring in youth occurs inconsistently.(AACAP, n.d.; Sanyal et al., 2024; Walkup & Work Group on Quality Issues, 2009) No studies have assessed the safety of psychiatric polypharmacy in youth. Moreover, caregivers are often unaware of the risks of psychiatric medications in youth, although side effects are their most frequent concern.(Barnett et al., 2019; Brinkman et al., 2011; McLaren et al., 2022) Calls, both professional and societal, to reduce the off-label use of antipsychotics and polypharmacy in youth are increasing(M. Boland et al., 2024; Keeshin et al., 2020; Kutz, 2012; Morgan & Baker, 2024; World Health Organization, n.d.; J. A. Zito, 2019), public concern is growing (Assistant Secretary for Public Affairs (ASPA), 2025; Richtel & Flanagan, 2022), and caregivers and prescribing clinicians are increasingly willing to consider reducing these medications.(Barnett et al., 2020; McLaren et al., 2022) The term deprescribing describes the process of prescribing clinicians (henceforth referred to as clinicians) and patients working together to reduce or remove medications based on effectiveness, side effects, and patient preferences.(Goldberg et al., 2025; Gupta et al., 2019) Deprescribing has been primarily described and studied in the elderly, with results demonstrating reduced side effects, fewer drug interactions, and improved health, mental health, and quality of life (Davies et al., 2020; Mohamed et al., 2020; Nieder et al., 2017)Within child psychiatry, studies of children in residential settings have demonstrated safe deprescribing of antipsychotics and polypharmacy, leading to less aggression, less use of restraints, and lower costs.(Bellonci et al., 2013; Connor & McLaughlin, 2005; Huefner et al., 2014; van Wattum et al., 2013) A body of literature has also emerged around deprescribing antidepressants in youth, with attention to individualized approaches.(Stimpfl et al., 2025) Shared decision making (SDM) is an approach where clinicians and patients collaborate to tailor treatment based on both clinical evidence and the patient's preferences.(Barnett et al., 2018; L. Boland et al., 2019; Making Shared Decision-Making A Reality , n.d., Patients’ Preferences Matter , n.d.; Wyatt et al., 2015) For youth, SDM requires a triadic process between the youth, caregivers, and clinicians. Although very few studies have examined shared decision making (SDM) in child psychiatry, there is evidence that youth and their caregivers want their voices heard.(Barnett et al., 2019; Brinkman et al., 2013; Pillen et al., 2024) Despite the need to engage youth and their caregivers in decisions about high-risk psychiatric medication and provide structured guidance to clinicians, there are no published structured deprescribing protocols available to support clinicians caring for outpatient youth. To address this gap, we aimed to develop and test the feasibility of an intervention that facilitates SDM between youth, caregivers, and clinicians and provides structured deprescribing guidance to clinicians caring for youth in outpatient settings. Methods Procedures Our evaluation adopted a mixed-methods approach, collecting data from online surveys, electronic health records (EHR), a smartphone app, and by interviewing clinicians and caregivers. We recruited clinicians and youth/caregiver dyads from two urban outpatient community mental health centers in New York between December 2023 and April 2024. Both clinics served Medicaid populations and accepted private insurance, offering a range of psychiatric, counseling, and case management services. Prescribing clinicians and clinic administrators identified all potentially eligible caregivers and youth from their client lists using electronic health record data. At the next clinic visit for each of the identified youth, clinicians briefly explained the study and obtained permission for the research team to talk with them. Prospective caregivers and youth participants were then contacted by a research assistant who provided copies of the informed consent and assent documents and conducted the consent discussion. Caregivers were compensated $ 30 for taking part in the consent discussion and $ 50 for each of the three research assessments completed. Those who completed an interview received an additional $ 75. This study was overseen by a single IRB, the Biomedical Research Alliance of New York (BRANY), and conducted in accordance with the Declaration of Helsinki as revised in 2024. Caregivers and youth provided written informed consent and written (ages 12–17 years) or verbal (ages 6–11 years) assent prior to engaging in any study activities. Clinicians provided written informed consent in advance of the qualitative interviews. Participants Inclusion criteria Eligible youth were: (a) aged 6–17 years, (b) prescribed psychiatric polypharmacy (3 or more concurrent medications) or an antipsychotic off-label for at least 3 months, and (c) had no hospitalizations, emergency room visits, or major life events (i.e., moving, changing schools) in the previous 3 months. Eligible caregivers (parents or guardians) were: (a) 18 years or older, (b) capable of providing informed consent, and (c) fluent in English. Eligible clinicians: (a) provided care to youth at one of the clinics and (b) were fully licensed to prescribe medications. Exclusion criteria Youth were considered ineligible if they: (a) had an acute crisis, (b) had a diagnosed substance use disorder, (c) were pregnant, or (d) were prescribed an antipsychotic for a condition approved by the FDA, such as a psychotic disorder, bipolar disorder, autism spectrum disorder with irritability/aggression, or Tourette’s disorder. Intervention The clinical research team developed a preliminary version of the intervention and accompanying tools and manual. Prior to study launch, the tools and manual were revised in partnership with our Advisory Group, comprising two child clinical prescribers and two parents of youth who had received psychiatric polypharmacy and off-label antipsychotics in the past. Phase 1. Shared decision making treatment review phase (~ 4 weeks) The intervention began with a collaborative treatment review during which the triad (clinician, caregiver, and youth) discussed the youth’s medications and made a shared decision regarding whether to try deprescribing a medication. This was completed in 1 or 2 sessions over the course of about 4 weeks. The triad considered whether each medication was improving symptoms, causing side effects, and still necessary. The research team did not impose any standards for which medication the triad might choose to try to deprescribe; decisions were individualized through the SDM process. SDM was supported by two tools: 1) a caregiver-facing Option Grid conversation aid (see Appendix S1), and 2) a smartphone-based chatbot app for caregivers (with a web portal for clinicians). The Option Grid supported SDM by describing five options, behavioral therapy plus four classes of medications, comparing the likely risks and benefits of each and providing plain language answers to frequently asked questions.(Barnett et al., 2018 ) The chatbot app contained the Option Grid content, other resource materials, and a treatment plan section that allowed caregivers to review various options, record their preferences, and leave comments that were viewable by clinicians in the web portal. The app also enabled caregivers to complete weekly health check-ins and an assessment of SDM.(Elwyn et al., 2013 ) Phase 1 ended with a shared decision whether or not to try deprescribing. Phase 2. Deprescribing and monitoring medications phase (~ 14 weeks) This phase was supported by a clinician-facing deprescribing protocol that facilitated tapering schedules and monitoring (see Appendix S2 and S3). Families who elected not to try deprescribing continued with their psychiatric care as usual. We modeled the protocol on existing structured guidance for deprescribing medications in the elderly (Bjerre et al., 2018 ) and on broad recommendations made by expert clinicians for children (Bellonci & Carlson, 2016 ; de Kuijper et al., 2014 ; Lohr, n.d.; Reeve et al., 2017 ; Scott et al., 2015 ). Protocol development involved multiple iterations, including consultation with 14 residents and fellows in psychiatry, tests of clinical utility by colleagues, and multiple changes as a result of feedback. When 9 pediatric clinicians confirmed that the protocol was practical, feasible, and usable, we completed a pilot test with 4 youth (age 6–17 years) taking atypical antipsychotics. Their medications were reduced or eliminated over a few months without adverse events. We then expanded the protocol to support deprescribing for polypharmacy, again based on existing guidance (Bellonci et al., 2013 ; Bellonci & Carlson, 2016 ; Connor & McLaughlin, 2005 ; Huefner et al., 2014 ; Lohr, 2019 ; Reeve et al., 2017 ; Scott et al., 2015 ), using feedback from 10 child psychiatry prescribers. As a research team, we provided 3 hours of training to participating clinicians, including didactic, discussion, and role plays. After describing the study, we discussed the challenges of providing psychiatric care to youth, described SDM, simulated the use of the Option Grid conversation aid, and reviewed the deprescribing protocol. We reinforced fidelity to the intervention through monthly consultation with the research team child psychiatrist/co-principal investigator (JM). Measures We conducted online caregiver assessments at baseline, 18, and 30 weeks after the first study visit. We collected medication reaction checklists and safety events from clinicians during clinic visits. We also obtained data from medical records, the smartphone app, and qualitative interviews with participants (see Table 1 ). Table 1 Measures, Sources & Assessment Schedule Measure Source Number of Items Response Scale Established Psychometrics Baseline Intervention Weeks 1–18 Post- Intervention Week 18 Follow-up Week 30 Online Assessments Demographics Caregiver 8 n/a n/a ✓ Demographics Youth 5 n/a n/a ✓ Youth impairment (CIS-P) Caregiver 13 0–4 ✓ ✓ ✓ ✓ Youth aggression (MOAS) Caregiver 4 0–4 ✓ ✓ ✓ ✓ Involvement in decisions (M-PICS) Caregiver 20 1–5 ✓ ✓ ✓ ✓ Demographics Clinician 7 n/a n/a ✓ Illness severity & improvement (CGI-S & CGI-I) Clinician 2 0–7 ✓ ✓ ✓ ✓ Youth impairment (CIS-Y) Youth a 13 0–4 ✓ ✓ ✓ ✓ Medication reactions (MRC) Clinician 60 b Yes / No no ✓ (each visit) Safety (adverse events) Clinician n/a n/a n/a ✓ (each visit) Electronic Health Record Diagnoses, date of birth, insurance payor Clinic Staff n/a n/a n/a ✓ Medications & dosages Clinic Staff n/a n/a n/a ✓ ✓ (each visit) ✓ ✓ Clinic visit type & date Clinic Staff n/a n/a n/a ✓ (each visit) ✓ ✓ Smartphone App Quality of SDM (collaboRATE) Caregiver 3 0–9 ✓ ✓ (wks 4, 8, & 12) Key areas of youth functioning Caregiver 6 0–5 no ✓ (weekly) Qualitative Interviews Intervention feasibility, acceptability, benefits, & ways to improve; opinions about medications, shared decision making, deprescribing & conversation aid Caregiver 10 Narrative n/a Caregivers were interviewed between weeks 18 and 30 (with one exception, one interview was 14 days after week 30) Intervention feasibility, acceptability, benefits, & ways to improve; effectiveness of training & support; opinions about medications, shared decision making, deprescribing & structured deprescribing protocol Clinician 10 Narrative n/a Clinicians were interviewed after all their participants had completed the study Note. n/a = not applicable;CIS-P = Columbia Impairment Scale, parent version; MOAS = Modified Overt Aggression Scale; M-PICS = Modified Perceived Involvement in Care Scale; CGI-S = Clinical Global Impression - Severity; CGI-I = Clinical Global Impression - Improvement; CIS-Y = Columbia Impairment Scale, youth version; SDM = shared decision making; wks = weeks. a Youth ages 12 and older were invited to complete the CIS-Y at each assessment point. b 60 possible medication reactions across 11 body systems based on the Psychotropic Medications Monitoring Checklist (PMMC) Online assessments Caregivers and clinicians completed online surveys through a HIPAA-compliant REDCap system. We used the Columbia Impairment Scale for caregivers and youth aged 12 and older(Attell et al., 2020 ; Cleverley et al., 2020 ; Singer et al., 2011 ) and the Clinical Global Impression severity (CGI-S) and improvement (CGI-I) clinician rating scales(Attell et al., 2020 ; Busner & Targum, 2007 ) to assess youth functioning. We measured youth aggression using the Modified Overt Aggression Scale (MOAS)(Kay et al., 1988 ) and the extent to which caregivers felt involved in clinical decisions using the Modified Perceived Involvement in Care Scale (M-PICS)((Smith et al., 2006 ) These online assessments were collected at baseline and 18 and 30 week follow up. We created a simple checklist, the Medication Reactions Checklist (MRC), with 60 negative medication reactions organized by 11 body systems (included as Appendix S4). These 60 reactions were taken from the Psychotropic Medication Monitoring Checklist (PMMC),(Ninan et al., 2014 ) which is widely used in clinical trials, but often considered too long and complicated for use in routine settings. We chose the terminology of “medication reactions” over the more widely used “side effects” because medication-related issues can encompass not only side effects but also withdrawal effects, medication interactions, or relapse in symptoms. Clinicians completed the MRC with caregivers and youth at each study visit, and probed for adverse events (e.g., hospitalizations, behavioral escalations). After the visit, clinicians then indicated whether the identified medication reactions were likely related to the study using their clinical judgment and knowledge of the youth’s history and current life experiences. Clinicians also reported any adverse events, including suicidality, to the research team. [insert Table 1 here] Medical records Site staff extracted the following data from the medical record: psychiatric diagnoses, date of birth, medications and dosages (used to calculate dose-weighted medication count), clinic visit types and dates, insurance coverage, and decision made after the SDM treatment review. Smartphone app data We collected data about the caregivers’ use of the app, including account activation, page visits, activities completed and dates of app usage. Caregivers were asked to complete two brief measures in the app: 1) a caregiver-reported level of perceived shared decision making (collaboRATE),(Barr et al., 2014 ; Elwyn et al., 2013 ; Scoring collaboRATE , n.d.) and 2) health/functioning in six key areas (called health check-ins). We created the health check-ins rating scale to track general functioning during the study; caregivers were prompted weekly to rate how much their youth had been affected in the areas of mood, behavior, sleep, ability to wake up/stay awake in the morning, ability to stay alert throughout the day, and appetite. Qualitative interviews We purposely invited 21 caregivers who had agreed to be interviewed and who differed in their clinician, clinic, decisions to deprescribe, app use, and caregiver and youth sex. We invited all 5 participating clinicians for interviews. Our interview guide covered the following topics: reactions to the interventions, the use of SDM, the Option Grid, the deprescribing protocol, smartphone app and web portal, and whether they would recommend changes to be made in future studies. We asked a researcher who was not part of the core study team (RB) to conduct the interviews. We followed the COnsolidated criteria for REporting Qualitative research standards of reporting qualitative research (COREQ) (Tong et al., 2007 ). Analyses Because of our small sample size, we did not have power to conduct any statistical tests of significance. Given the primary objective of the study was to understand the feasibility of the intervention and study procedures, we conducted descriptive statistics and examined patterns over time in our quantitative data, and thematic analyses on our qualitative data. Our results are reported as frequencies and percentages for categorical data, means and standard deviations for continuous data, and most common themes from our qualitative interviews. We calculated dose-weighted medications instead of a simple medication count to reflect reductions in dose. The number of dose-weighted medications at each follow-up point was calculated as a sum of the proportion of the current dose of each medication compared to the sum of the baseline doses of those medications. For example, if a participant was taking 100 mgs of trazodone and 25 mgs of zoloft daily at baseline and 50 mgs of trazodone and 25 mgs of zoloft daily at 18-week follow-up, the dose-weighted number of medications at follow-up would be 1.5 (whereas a straight count of medications at follow-up would be 2). Participants had varying numbers of visits during the study, based on clinical need, which resulted in differing numbers of clinician-rated medication reaction checklists (MRCs). To eliminate the problem of unequal numbers of completed MRCs across participants and to reflect changes in negative medication reactions from study initiation to final follow-up assessment, we compared each participant’s first completed MRC to their last MRC. We adopted the Practical Thematic Analysis approach to qualitative interviews.(Saunders et al., 2023 ) EB and RB read all transcripts, created a code book, conducted double-coding on 8 transcripts before individually coding the rest, and independently drafted a set of themes based on the coding. A third researcher (HL) facilitated a collaborative theming process to finalize the themes and these were reviewed by all authors for approval. Results Feasibility We identified 39 eligible youth/caregiver dyads, enrolled 31, and provided the intervention to 29. Of those 29, 20 (69%) completed the 18-week follow-up assessment and 15 (52%) completed the 30-week follow-up assessment. See Fig. 1 for details. For qualitative interviews, we approached 21 caregivers and all 5 clinicians; 10 caregivers (48%; 2 declined, 9 could not be reached) and 4 clinicians agreed to participate (80%; 1 declined). As shown in Table 2 , most of the participants were White, non-Hispanic, and covered by public insurance; 85% of caregivers were female and 63% of youth were male. Mean caregiver and youth ages were 40 and 12 years, respectively. Youth received a mean of 3.6 concurrent medications and the most common diagnosis was attention deficit hyperactivity disorder (ADHD); 66% of youth were taking an antipsychotic medication (either alone or as part of polypharmacy). The majority of clinicians were female, White, and non-Hispanic, providing care to both youth and adults. Demographics of caregivers, youth, and clinicians who were interviewed were representative of the full sample. Table 2 Characteristics of Caregivers, Youth and Clinicians Characteristic N % Mean SD Caregivers (n = 31) a Sex (female), n = 27 23 85% - - Race (White), n = 27 25 93% - - Ethnicity (not Hispanic), n = 26 20 77% - - Marital status (married), n = 27 15 56% - - Education level, n = 26 High school or less 8 31% - - Some college or 2-year degree 9 35% - - 4-year college or graduate degree 9 35% - - Relationship to child (mother/step-mother), n = 27 19 70% - - Age (in years), n = 25 - - 40.0 10.1 Children (n = 31) b Sex (male), n = 27 17 63% - - Race (White), n = 27 23 85% - - Ethnicity (not Hispanic), n = 27 21 85% - - Age (in years), n = 23 - - 12 3.7 Primary insurance (public/Medicaid) (n = 29) 27 93% Psychiatric medications (n = 29) Total number - - 3.6 1.1 Polypharmacy c (no antipsychotic) 10 34% - - Polypharmacy c with an antipsychotic or antipsychotic only 19 66% - - Most common diagnoses b,d (n = 29) Attention deficit hyperactivity disorder (ADHD) 24 83% - - Disruptive, Impulse Control & Conduct Disorder 14 48% - - Anxiety Disorders 12 41% - - Other 12 41% - - Clinicians (n = 5) Sex (female) 3 60% - - Race (White) 4 80% - - Ethnicity (not Hispanic) 5 100% - - Patient population (pediatric & adult) 4 80% - - Age (in years) - - 49.5 10.99 Years in practice - - 15.8 12.52 a Four caregiver participants did not complete the baseline survey with caregiver demographics. b Four caregiver participants did not complete the baseline survey with youth demographics; an additional 4 caregivers did not complete youth age. In addition, EMR data from the 2 participants who dropped out before the intervention were not available. c Polypharmacy is defined as 3 or more concurrent medications. d Totals exceed 100% because most participants had more than one diagnosis. [insert Table 2 here] All caregivers were invited to use the smartphone chatbot application and associated resources. Of the 29 who received the intervention, 22 (76%) activated their app account. Caregivers most commonly used the treatment section, where options, preferences, and plans could be reviewed and comments made (62%, n = 18 of 29), while only 21% (n = 6 of 29) accessed the resources section. The collaboRATE survey was also embedded within the app. Response rates were too low to run analyses; only 10 of 29 (34%) caregivers completed at least one survey. Figure 1 demonstrates the total number of participants eligible, recruited, consented/assented, and engaged in SDM treatment review during our study. This diagram also shows the number of participants who chose to deprescribe, remained undecided, or chose to not deprescribe, as well as the number of participants who completed each survey Process outcomes Choice to deprescribe Thirteen (45%) of the 29 participants chose to try deprescribing a medication; 12 (41%) did not choose to deprescribe, and 4 (14%) remained undecided. These 4 were included with the 12 who did not choose to deprescribe for the comparisons described below. Of the 13 who began deprescribing, 7 discontinued the medication entirely, 4 reduced dose (3 by 50% or more) and remained on the lower dose, and 5 chose to deprescribe a second medication. Two of the 13 stopped deprescribing and returned to their original dose. The following medications were chosen for deprescribing: risperidone, buspirone HCl, guanfacine, prazosin, fluoxetine, clonidine, aripiprazole, citalopram, amphetamine/dextroamphetamine, lurasidone, trazodone, and cyproheptadine. Five youth then chose to deprescribe a second medication, which included: amphetamine/ dextroamphetamine, clonidine, risperidone, hydroxyzine, and guanfacine. The two youth who stopped deprescribing and returned to their original dose were receiving cyproheptadine and trazodone. For the former, cyproheptadine was being taken to stimulate appetite due to stimulant use, and the youth’s appetite reduced when they stopped the periactin. For the latter, trazodone was being taken to help with sleep, and the youth’s sleeping difficulties returned. Caregiver involvement in decisions Caregivers reported moderate levels of perceived involvement in decisions related to their child’s psychiatric care, and these reports were relatively stable across time points. Patterns in these perceptions were similar for the full sample and by group (chose vs. did not choose to deprescribe). Outcomes Dose-weighted number of medications For the full sample (N = 29), the average number of dose-weighted medications reduced from 3.6 (SD = 1.09) at baseline to 3.1 (SD = 1.35) at 30-week follow-up. In group comparisons, there was a greater reduction in dose-weighted medications for those who chose to deprescribe (3.9 at baseline to 2.9 at 30-week follow-up) than for those who did not choose to deprescribe (from 3.4 at baseline to 3.2 at 30-week follow-up). See Table 3 and Fig. 2 . Table 3 Youth Outcomes by Group Total Sample Chose to Deprescribe Did Not Choose to Deprescribe (N = 29) (n = 13) (n = 16) T0 T1 T2 T0 T1 T2 T0 T1 T2 Measure M SD M SD M SD M SD M SD M SD M SD M SD M SD Dose-Weighted Medications 3.59 1.09 3.09 1.30 3.05 1.35 3.85 1.28 3.01 1.29 2.87 1.41 3.38 0.89 3.15 1.35 3.19 1.32 Negative Medication Reactions a 0.93 1.62 0.17 0.38 - - 1.31 2.21 0.31 0.48 - - 0.63 0.89 0.00 0.00 - - Functioning Youth impairment (CIS-P) 24.3 9.8 24.3 11.5 23.8 11.4 20.6 10.79 23.4 12.89 23.8 12.27 27.7 7.70 25.2 10.64 23.7 11.13 Youth aggression (MOAS) 10.1 7.63 13.1 10.25 12.3 10.14 11.8 7.32 13.7 10.58 10.2 7.81 8.5 7.86 12.4 10.43 14.9 12.72 Youth impairment (CIS-Y) b 34.6 12.54 34.1 11.93 34.5 12.11 - - - - - - - - - - - - Illness severity (CGI-S) 4.1 0.8 3.6 0.8 3.4 1.2 4.0 0.71 3.5 0.78 3.7 0.85 4.2 0.83 3.6 0.91 3.2 1.42 Illness improvement c (CGI-I) - - 3.4 0.83 2.5 1.07 - - 3.3 0.95 2.8 1.01 - - 3.4 0.74 2.3 1.10 Note. T0 = baseline; T1 = 18 weeks post first study visit; T2 = 30 weeks post first study visit; M = mean; SD = standard deviation; CIS-P = Columbia Impairment Scale, parent version; MOAS = Modified Overt Aggression Scale; CIS-Y = Columbia Impairment Scale, youth version; CGI-S = Clinical Global Impression - Severity; CGI-I = Clinical Global Impression - Improvement. For all functioning measures, higher scores are worse (e.g., higher impairment, aggression, illness severity, and less improvement). a Negative medication reactions checklists were completed by the clinician at each clinic visit during the intervention period. Participants had a varying number of visits during the study, so we compared the first checklist completed to the last checklist completed. T0 = first medication checklist completed, T1 = last checklist completed, T2 = not applicable. b Only 17 youth completed the CIS-Y at baseline, 12 at 18 weeks, and 8 at 30 weeks. Sample sizes when split into decision groups are too small to display. c There is no improvement rating at T0 because there is no previous rating with which to compare. Negative medication reactions For the full sample, the average number of negative medication reactions reduced from 0.9 (SD = 1.69) on the initial checklist to 0.2 (SD = 0.38) on the final checklist. Those who chose to deprescribe showed a greater reduction in negative medication reactions (from 1.3 to 0.3) compared to those who did not choose to deprescribe (0.6 and 0.0, respectively). [insert Table 3 here] Figure 2 . Dose Weighted Number of Medications Figure 2 a. Dose-weighted medication count by group over time showing mean medication counts at baseline, 18 weeks, and 30 weeks for participants who did not choose to deprescribe (blue line), participants who chose to deprescribe (red line), and the total sample (green line), demonstrating a decrease in medication count over time with a slightly greater reduction among participants who chose to deprescribe Figure 2 b. Number of negative medication reactions by group over time showing mean number of reactions at first visit and last visit for participants who did not choose to deprescribe (blue line), participants who chose to deprescribe (red line), and the total sample (green line), demonstrating a decrease in negative medication reactions across all groups over time Safety There were no study-related serious adverse events or behavioral escalations reported by participants or clinicians. As reported above, the number of negative medication reactions reduced for all participants. The study clinicians judged that for seven participants, the identified negative medication reactions may have been related to study deprescribing. The reactions were minor and included: feeling depressed, trouble sleeping, decreased appetite, agitation/irritability, hyperactivity/impulsivity, problems focusing, and feeling jittery. Five participants tolerated the reactions well and continued to deprescribe; two decided to stop deprescribing due to trouble sleeping (trazadone) and decreased appetite (cyproheptadine) and return to their original dose. Functioning For the full sample (N = 29), outcome measures related to youth functional impairment, illness severity and improvement appeared similar across time points. These patterns were also true when comparing those who chose to deprescribe (n = 13) with those who did not choose to deprescribe (n = 16). Aggression ratings remained fairly stable for the full sample and those choosing to deprescribe, but trended towards getting worse for those choosing not to deprescribe. See Table 3 and Fig. 3 . [insert Table 3 here] Figure 3 . Clinician and Caregiver Functioning Results Figure 3 a Clinician-rated illness severity by group over time showing mean severity ratings at baseline, 18 weeks, and 30 weeks for participants who did not choose to deprescribe (blue line), participants who chose to deprescribe (red line), and the total sample (green line), demonstrating a decrease in severity across time points with slightly greater reductions in the non-deprescribing group by 30 weeks Figure 3 b. Clinician-rated improvement by group over time showing mean improvement ratings at 18 weeks and 30 weeks for participants who did not choose to deprescribe (blue line), participants who chose to deprescribe (red line), and the total sample (green line), demonstrating modest declines in improvement ratings over time with similar trajectories across groups Figure 3 c. Caregiver-rated youth impairment Fig. 3 d. Caregiver-rated youth aggression Figure 3 d. Caregiver-rated youth aggression by group over time showing mean aggression ratings at baseline, 18 weeks, and 30 weeks for participants who did not choose to deprescribe (blue line), participants who chose to deprescribe (red line), and the total sample (green line), demonstrating increasing aggression over time in the non-deprescribing group and a decrease by 30 weeks in the deprescribing group Qualitative outcomes We identified six caregiver and five clinician themes. Several themes converged between groups, including fit between the intervention and prior beliefs; the need for strong relationships between youth, caregivers, and clinicians; the importance of a triadic SDM process; increased caregiver knowledge about medications due to the intervention; and a positive research process. See Table 4 for exemplar quotes from caregivers and clinicians. Table 4 Caregiver Themes and Illustrative Quotes Theme Supporting Quotes Caregivers’ views aligned with the goals of SDM and treatment optimization “I think it just made me a little bit more aware of looking at other possible medications and trying to be more of an advocate for her…trying to make sure that she realizes this is not something we're doing to her. It's something we're doing with her.” Caregiver 6 “At first, I was really nervous…after we did it, and we ran into a hitch with the first time, so we lowered a different medication. Now she's lowered [a medication] down to a lot, and she's even off some medications.” Caregiver 2 “Just the open line of communication is huge. Paying attention to the signs and symptoms that the kids are having, concerns that you might be having, reasons as to why you would want to change or lower. I mean, there's a lot that goes into that kind of decision-making.” Caregiver 5 Existing positive relationships with clinicians influenced decisions “We have considered, and we've been working with our provider to lower [medications] a little bit. We will take a medicine and say, ‘Is this the time to start lowering it?’ You seem to be doing a good job...” So that's something our prescriber has been doing all along. She's really been working hard at that.“ Caregiver 4 “We've built a good relationship with her [clinician]. My daughter trusts her. I trust her, and it's been a really good experience with her.” Caregiver 3 “I felt pretty involved. I mean, not so much as choosing the med because she [clinician] made the recommendations… but she involved us in educating us on the medication and the side effects and everything else.” Caregiver 9 The collaborative team-based approach, inclusive of the youth, was valued “We've kind of always, in the past, kind of always been blindly doing what the doctor said. Partly because, in the past, we didn't really have a say. Some of these kids were foster kids, and it's like, ‘Well, you do what we tell you to, whether you like it or not.’ So being able to have this conversation with the doctor is just very freeing and liberating. I love being able to be a part of that discussion.” Caregiver 6 “I think that they have to look at everything…to come to a team decision with the provider and the child and the parent all together… the provider has some insight of seeing things sometimes that we don't see… but the parent can be there to tell the provider what's going on…because the provider's not in the home.” Caregiver 9 Caregivers reported increased knowledge and empowerment “I'm actually very grateful for the study because had we not gotten involved, I would not have known that about the risperidone [side effects].” Caregiver 6 “I do feel like I learned a lot more about my daughter's medications than anything else and different options that are out there to help proceed with certain situations.” Caregiver 1 “I definitely learned a lot more details in depth with the medications and how they function and work together. And also that open line of communication more– I spoke up before, my concerns, but I definitely opened up more to say, ‘Hey, this was working, but I don't think this is working anymore, and I want to try something else.’” Caregiver 7 “I found that [Option Grid]incredibly helpful. There were a couple of things I didn't know. I mean, we've been a therapeutic foster home for 15 years, so we have experience with a lot of medications, but some of that I didn't know, so I found it incredibly helpful.” Caregiver 6 Caregivers reported positive outcomes “I think it's a really great project that's very beneficial and helpful overall…it's more of a team effort all the way around to benefit the child and the care so a parent and provider can work together.” Caregiver 7 “When she first started trying to come off the Abilify, she got very aggressive. So he [clinician] put it back up, and then he stopped the Buspirone. So that helped, and then she was off Doxepine next, and then we just cut the Abilify, and she's doing very well with it.” Caregiver 2 Caregivers were positive about the research processes “People were very attentive to our time schedule, and they were very– explained everything about the process of the survey and the questioning and very upfront. And I never felt like we were forced into doing anything. And my daughter felt very comfortable when she talked to everyone.” Caregiver 9 Caregivers Caregivers’ views aligned with the goals of SDM and treatment optimization. All of the caregivers interviewed felt the study’s approach to medications aligned with their beliefs about how decisions should be made and about the use of psychotropic medication for their youth. They preferred a “less is more” approach: “ I don't want him to take all these medications. I want a root cause as to what's actually wrong with him ” (Caregiver 3). Many reported having anxiety about the initiation of medication: “ My biggest concern with any medication, really, is the side effects… ” (Caregiver 7). However, caregivers had mixed reactions when clinicians suggested deprescribing. Some had already considered it; for others, the idea was new: “ No, I never considered it. I thought she would always be on all the meds the rest of her life ” (Caregiver 2). Some admitted anxiety about the possibility. Many were pleased because it addressed their concerns about the side effects or allowed for more individualized care. Existing positive relationships with clinicians influenced decisions. Collaborative and trusting relationships fostered confidence in medication decisions and helped families feel supported: “ We've had a good relationship with the prescriber all along, and she gives us all the options and makes sure that we are very well aware of the possibilities of what may happen or may not happen, and she talks about everything very well ” (Caregiver 3). The collaborative team-based approach, inclusive of the youth, was valued. Caregivers valued the team-based SDM process. “I felt that the process itself, working together as a team, felt like he [youth] knows that he has support of all these people” ( Caregiver 4 ). Nearly all caregivers valued the youth’s preferences and appreciated that the intervention reinforced youth autonomy: “ At the end of the day, she's the one that has to take the meds. It's her body. I want her to make her own decisions for her own body… ” (Caregiver 1). Caregivers reported increased knowledge and empowerment. The intervention increased caregivers' understanding of medications and encouraged more active involvement, leading to informed and empowered decisions. Caregivers especially liked the Option Grid decision aid in helping them make decisions. I found it [Option Grid] useful because then I knew what kind of medications he would be taking…Then I could see if there was any side effects, what other medications he would be going on, or the classifications to just know in general. So I had a better understanding of how they're going to help them or work together. (Caregiver 7) If the caregivers used the app, they appreciated the weekly symptom tracking feature, which reminded them to pay attention to their youth’s functioning and side effects. Caregivers reported positive outcomes. Those who chose to deprescribe typically saw reductions in negative medication reactions and behaviors: So the one big thing that we noticed, believe or not, we noticed a huge change in less aggression. We also noticed, according to his endocrinologist, less gynecomastia, his gynecomastia stopped growing. So that was huge for Michael. We also noticed for him, he stopped putting on weight. He actually started losing weight. (Caregiver 6) Those who did not deprescribe still felt successful; caregivers felt more empowered and equipped to have these discussions about deprescribing in the future. Caregivers were positive about the research processes . Caregivers were overwhelmingly positive about the research process. They appreciated the clear consent process, brief surveys, and the respectful, accommodating research staff. [insert Table 4 here] Clinicians Clinicians’ (and their clinics’) views aligned with SDM and treatment optimization. Clinicians found it easy to integrate the intervention because it aligned with their own and their clinic’s philosophies related to SDM and a “less is more” approach. As stated by one clinician: “I've always considered myself a collaborator…I'm a collaborator with the parent, with the family, with the teacher, with the kid, with the patient. Like a journey. Walking together ” (Clinician 2). Clinicians also highlighted shared values across their agency: “… We try to do it [deprescribe] all the time. That's our goal is to try to have them on the least amount of medication or no medication ” (Clinician 3). Similarly: I think the other practitioners we have at this site, it's just kind of something that we all naturally do. It doesn't feel good for families, and it doesn't feel good for the providers to have polypharmacy or using medications that are off-label. It just doesn't feel good. (Clinician 1) Clinicians appreciated the structured framework and intervention tools. Clinicians valued how the intervention structured collaboration and deprescribing. As one stated: I like that it [the intervention] ensures that caregivers, particularly, maybe some teenagers, are aware that that [deprescribing] is a priority, that that is encouraged, and it's on paper. It [the intervention] sort of puts it to the forefront. (Clinician 3) Similar to caregivers, clinicians valued the triadic SDM process between youth, caregivers, and clinicians, noting how the intervention enhanced this triadic process. Clinicians, like caregivers, also appreciated the Option Grid tool, in particular. I liked the Option Grid because I think it's nice to have had all the information in one place to be able to hand it to them and let them take with them. I think it's a lot of stuff that we go over with people…But to have it on paper and to really be able to see it. (Clinician 1) There were mixed thoughts about whether they would use the other study tools (e.g. web-based portal that accompanied caregiver mobile phone app) in the future. Clinicians provided considerations for implementation. Clinicians emphasized the importance of timing when deprescribing based on the youth’s stability in symptoms and life events. Some reported maintaining doses between reduction increments longer than the protocol’s recommended schedule: I think sometimes there's fear around changing that or rocking the boat. And so going slower, I think a lot of them did. I still have a couple that, after the 18 weeks, were still in process because some sort of went down on a medication and then wanted to wait a little while and then consider the next one. (Clinician 1) Clinicians discussed the importance of acknowledging the success of dose reductions, not just removals. Clinicians also prioritized caregiver engagement and comfort with the treatment decision. It was important for caregivers to not have to commit to deprescribing to be part of the study. Similar to caregivers, clinicians agreed that although caregivers had mixed initial reactions, caregivers frequently felt relieved from their discomfort with the medications in the first place. Still, in some cases, caregiver fears about their youth’s decompensation led to maintaining the youth’s medication regimen. Finally, some clinicians suggested that the intervention be supplemented by additional education or non-pharmacological interventions. Clinicians recommended expanding the concept and practice of deprescribing. Clinicians perceived deprescribing as an ethical imperative: “ It's a moral and ethical issue to not be continuing people on medications without good, documented reasons ” (Clinician 2). They described a need for these concepts and practices to permeate the field, including incorporation into medical training and continuing medical education: So I think we need a cultural change. We're always pushing to prescribe, … But you don't really hear, "Okay. Once your person is better, when do you think about starting to take them off that medication?" And so when you bring that up, kind of are on your own. (Clinician 2) Clinicians felt prepared and supported by the research team. The prescribers felt well prepared and supported through training resources and monthly consultations with the research team’s child and adolescent psychiatrist. Clinicians found the research process to add very little to their workload. In addition, their internal clinic administrative support further reinforced the adoption of the intervention. Differing perspectives between caregivers and clinicians Clinicians reported that the structured deprescribing guidance may need to consider slower tapering. Clinicians also recommended adding extra supports or non-pharmacological interventions when deprescribing. However, caregivers did not mention these needs. In addition, whereas clinicians were mostly motivated to deprescribe based on the youth’s stability in symptoms, caregivers were mostly motivated by the potential to reduce negative medication reactions. [insert Table 5 here] Table 5 Clinician Themes and illustrative Quotes Theme Supporting Quotes Clinicians’ and clinics’ views aligned with SDM and treatment optimization “I usually always talk to the patients and family right off the bat. That, "Just because we're starting this medication now doesn't mean it's something that's going to be forever, and that our ultimate goal would be to try to see if we can get you off the medication," and encouraging them to participate in their therapy…And then once their symptoms are stable, the goal is to try to bring down those medications.” Clinician 4 “I try to have patients more so be aware that we ramp up and we also ramp down ahead of time…that this is not just something we're going to slap them on, as we say, and leave it alone. It's an actively managed process even when we find the right doses and such because things change over time….” Clinician 3 Clinicians appreciated the structured framework and intervention tools I think sometimes it's just hard to keep track of a lot of the stuff that you hear in appointments like that - and just making sure everything gets talked about and the questions that they have get answered. So I think it helped structure that a little bit in a nice way.” - Clinician 1 Clinicians provided considerations for implementation “I think a lot of times, caregivers of kids on medicine, they're just waiting to get the kid off…caregivers of kids are usually reluctant, and they're sort of last resort to prescribe. And so then when you're talking about deprescribing, it was very well received.” Clinician 2 Clinicians recommended expanding the concept and practice of deprescribing “So I'd like to see it [deprescribing] expanded into training, into nursing, into social working, so when everyone's sitting down, just like we look out for child abuse, we look out for these things.” Clinician 2 Clinicians felt prepared and supported by the research team “I don't think there was anything burdensome about it. There were a couple of things that were just a little different in terms of the way that we were documenting but still all stuff that we would have done in the course of an appointment, like the medication reaction checklist.” Clinician 1 “Folks seem very passionate. And I just thought it was helpful to really be presented with well-thought-out, well-researched points of view that made sense about deprescribing.” Clinician 2 Discussion We demonstrated the feasibility of our study procedures and intervention. Caregivers and clinicians were positive about the intervention and study processes. About half of the triads chose to try deprescribing; no study-related serious adverse events occurred. The intervention seemed to reduce the number of medications and medication reactions, although the small sample and low baseline rates of medication reactions preclude firm conclusions. Qualitative themes suggested that the “less is more” approach aligned with the beliefs of our participating clinics and clinicians, and the intervention provided a structure to make SDM and deprescribing a reality. The strengths of our study include its mixed methods approach and real world context. To our knowledge, this is the first study of a structured, deprescribing protocol within child psychiatry. However, we have several limitations. This is a small feasibility study limited to two motivated, innovative clinics with values that align with deprescribing. The findings may not be generalizable to all settings. We were unable to distinguish between potential side effects, withdrawal symptoms, and relapse symptoms within our negative medication reactions checklist. Our medication review checklist was modified from the original version and not validated, and the brief caregiver-rated youth health check-ins within the phone application was not validated. We also had high rates of missing data on the caregiver-rated collaboRATE and youth health check-ins, which were collected via the app. Deprescribing interventions include patient education, clinician audits, pharmacy reviews, and the use of structured protocols. In large reviews targeting the reduction of polypharmacy in various populations, deprescribing has led to efficacy for physical health outcomes in certain groups(Adams et al., 2023 ), but not all.(Keller et al., 2024 ) The use of structured tapering protocols and interventions used during the clinical encounter may be important in psychiatry.(Christensen et al., 2025 ; Jerjes et al., 2024 ; Mølgaard et al., 2024 ) To our knowledge, only one study has specifically investigated a structured deprescribing intervention in child psychiatry among youth seeking outpatient care. No patient-provider interaction or structured tapering protocol was used, and the authors reported no effects on medication (i.e., antipsychotic) use.(Penfold et al., 2025 ) More recently, deprescribing interventions with a very slow approach that use smaller and smaller incremental dose reductions over time are being promoted by the scientific and lived-experience communities.(Campbell et al., 2024 ; Horowitz & Taylor, 2024 ; Ramsdale et al., 2024 ) In future studies, it will be important to improve measurement of relapse vs. withdrawal, follow participants longer, and test various deprescribing approaches and paces that may reduce withdrawal symptoms or relapse,(Stimpfl et al., 2025 ) including the hyperbolic approach to tapering medications.(Horowitz & Taylor, 2024 ; Stimpfl et al., 2025 ) Finally, the intervention needs to be tested in other settings and in larger studies, ideally through randomized controlled trials, to test its effectiveness and safety. Conclusions Caregivers, youth, and clinicians were highly motivated to deprescribe through a SDM process in outpatient settings. Our intervention demonstrated feasibility and, although conclusions are limited by our small sample, our intervention was associated with a reduction in the number of medications and negative medication reactions. We plan to test our intervention in a larger and more rigorous trial. Meanwhile, child psychiatry leaders and researchers can incorporate our findings into their clinical practice, advocacy, and policy efforts. Declarations Ethics approval and consent to participate The study was approved by the BRANY Institutional Review Board (Protocol #32704, Master File #23-10-216). Clinicians, caregivers, and youth provided informed consent / assent prior to the initiation of study activities. Consent for publication Not applicable Competing Interests Glyn Elwyn’s academic interests are focused on shared decision making and coproduction. He is the editor of the 4th edition of the Textbook of Shared Decision Making (Oxford University Press, 2025). He is the Founder and Director of &think LLC, which owns the registered trademark for Option Grid.TM He owns copyright in measures of shared decision making and care integration, namely collaboRATE, integRATE, Observer OPTION-5, and Observer OPTION-12. These measures are freely available. Ben Fehnert and James King are co-founders of Fora Health, the company responsible for developing and providing the app utilized in this study. All other authors report no disclosures. Funding This research was funded by The Charles H. Hood Foundation, Inc. Author Contribution ERB- Funding acquisition, conceptualization, data curation, formal analysis, supervision, writing (original draft), methodology. JLM- Funding acquisition, conceptualization, data curation, formal analysis, supervision, writing original draft, methodology. GE- Funding acquisition, conceptualization, supervision, writing (original draft), methodology. SCA- Funding acquisition, conceptualization, data curation, formal analysis, writing (original draft), project administration, methodology. HBL-, data curation, formal analysis, writing (original draft), project administration, methodology. SB- implementation, writing (review and editing), methodology . AG- implementation, writing (review and editing), methodology. RB- data curation, formal analysis (qualitative), writing (review and editing). JK- Technology development, writing (review and editing), methodology. BF- Technology development, writing (review and editing), methodology. Acknowledgement We wish to extend our gratitude to the participants in this study for sharing their experiences and joining us in this endeavor. We are also thankful for the clinicians, staff and clinic administrators who worked so hard to make the study possible. 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Ensuring appropriate use of psychotropic medications in pediatrics: Best practices in medication discontinuation (deprescribing). In Pediatric Psychopharmacology Evidence (pp. 63–80). Springer Nature Switzerland. https://doi.org/10.1007/978-3-031-57472-6_4 Nieder, C., Mannsăker, B., Pawinski, A., & Haukland, E. (2017). Polypharmacy in older patients ≥ 70 years receiving palliative radiotherapy. Anticancer Research , 37 (2), 795–799. https://doi.org/10.21873/anticanres.11379 Ninan, A., Stewart, S. L., Theall, L., King, G., Evans, R., Baiden, P., & Brown, A. (2014). Psychotropic medication monitoring checklists: use and utility for children in residential care. Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l’Academie Canadienne de Psychiatrie de L'enfant et de L'adolescent , 23 (1), 38–47. https://www.ncbi.nlm.nih.gov/pubmed/24516476 Olfson, M., King, M., & Schoenbaum, M. (2015). Treatment of young people with antipsychotic medications in the United States. JAMA Psychiatry , 72 (9), 867–874. https://doi.org/10.1001/jamapsychiatry.2015.0500 Patients (2024). ’ Preferences Matter . (n.d.). The King’s Fund. Retrieved October 17, from https://www.kingsfund.org.uk/publications/patients-preferences-matter Penfold, R. B., Idu, A. E., Coley, R. Y., Cushing-Haugen, K. L., King, D., Glass, A., Phillips, R. C., Renz, A. D., Pabiniak, C. J., Graham, V. F., Thompson, E. E., Ralston, J. D., Simon, G. E., Gonzalez, E. S., Myers, K. M., Beck, A., Quintana, L. M., Runkle, A. J., Rogers, M., & Hilt, R. J. (2025). Safer and targeted use of antipsychotics in youth: an embedded, pragmatic randomized trial. Journal of Child Psychology and Psychiatry and Allied Disciplines , 66 (3), 301–310. https://doi.org/10.1111/jcpp.14059 Pillay, J., Boylan, K., Carrey, N., Newton, A., Vandermeer, B., Nuspl, M., MacGregor, T., Jafri, S. H. A., Featherstone, R., & Hartling, L. (2017). First- and Second-Generation Antipsychotics in Children and Young Adults: Systematic Review Update . Agency for Healthcare Research and Quality (US. https://www.ncbi.nlm.nih.gov/pubmed/28749632 Pillen, S., Glazemakers, I., & Bal, S. (2024). Kwalitatief onderzoek naar gedeelde besluitvorming over psychofarmaca bij jongeren. Tijdschrift Voor Psychiatrie , 125–129. Ramsdale, E., Mohamed, M., Holmes, H. M., Zubkoff, L., Bauer, J., Norton, S. A., & Mohile, S. (2024). Decreasing polypharmacy in older adults with cancer: A pilot cluster-randomized trial protocol. Journal of Geriatric Oncology , 15 (2), 101687. https://doi.org/10.1016/j.jgo.2023.101687 Reeve, E., Thompson, W., & Farrell, B. (2017). Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. European Journal of Internal Medicine , 38 , 3–11. https://doi.org/10.1016/j.ejim.2016.12.021 Richtel, M., & Flanagan, A. (2022, August 27). This Teen Was Prescribed 10 Psychiatric Drugs. She’s Not Alone. The New York Times . https://www.nytimes.com/2022/08/27/health/teens-psychiatric-drugs.html Sanyal, S., Calarge, C., Rowan, P. J., Aparasu, R. R., Abughosh, S., Sisley, S., & Chen, H. (2024). Adherence to recommended metabolic monitoring of children and adolescents taking second-generation antipsychotics. Psychiatric Services (Washington D C) , 75 (4), 342–348. https://doi.org/10.1176/appi.ps.20220584 Saunders, C. H., Sierpe, A., von Plessen, C., Kennedy, A. M., Leviton, L. C., Bernstein, S. L., Goldwag, J., King, J. R., Marx, C. M., Pogue, J. A., Saunders, R. K., Van Citters, A., Yen, R. W., Elwyn, G., & Leyenaar, J. K. (2023). Practical thematic analysis: a guide for multidisciplinary health services research teams engaging in qualitative analysis. BMJ (Clinical Research Ed) , 381 , e074256. https://doi.org/10.1136/bmj-2022-074256 . & Coproduction Laboratory Scoring collaboRATE . (n.d.). Glyn Elwyn. Retrieved February 13, (2025). from https://www.glynelwyn.com/scoring-collaborate.html Scott, I. A., Hilmer, S. N., Reeve, E., Potter, K., Le Couteur, D., Rigby, D., Gnjidic, D., Del Mar, C. B., Roughead, E. E., Page, A., Jansen, J., & Martin, J. H. (2015). Reducing inappropriate polypharmacy: the process of deprescribing: The process of deprescribing. JAMA Internal Medicine , 175 (5), 827–834. https://doi.org/10.1001/jamainternmed.2015.0324 Simmel, C., Bowden, C. F., Neese-Todd, S., Hyde, J., & Crystal, S. (2021). Antipsychotic treatment for youth in foster care: Perspectives on improving youths’ experiences in providing informed consent. The American Journal of Orthopsychiatry , 91 (2), 258–270. https://doi.org/10.1037/ort0000532 Singer, J. B., Eack, S. M., & Greeno, C. M. (2011). The Columbia Impairment Scale: Factor analysis using a community mental health sample. Research on Social Work Practice , 21 (4), 458–468. https://doi.org/10.1177/1049731510394464 Smith, M. Y., Winkel, G., Egert, J., Diaz-Wionczek, M., & DuHamel, K. N. (2006). Patient-physician communication in the context of persistent pain: validation of a modified version of the patients’ Perceived Involvement in Care Scale. Journal of Pain and Symptom Management , 32 (1), 71–81. https://doi.org/10.1016/j.jpainsymman.2006.01.007 Stimpfl, J. N., Walkup, J. T., Robb, A. S., Alford, A. E., Stahl, S. M., McCracken, J. T., Stancil, S. L., Ramsey, L. B., Emslie, G. J., & Strawn, J. R. (2025). Deprescribing antidepressants in children and adolescents: A systematic review of discontinuation approaches, cross-titration, and withdrawal symptoms. Journal of Child and Adolescent Psychopharmacology , 35 (1), 3–22. https://doi.org/10.1089/cap.2024.0099 Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care , 19 (6), 349–357. https://doi.org/10.1093/intqhc/mzm042 van Wattum, P. J., Fabius, C., Roos, C., Smith, C., & Johnson, T. (2013). Polypharmacy reduction in youth in a residential treatment center leads to positive treatment outcomes and significant cost savings. Journal of Child and Adolescent Psychopharmacology , 23 (9), 620–627. https://doi.org/10.1089/cap.2013.0014 Walkup, J., & Work Group on Quality Issues. (2009). Practice parameter on the use of psychotropic medication in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry , 48 (9), 961–973. https://doi.org/10.1097/CHI.0b013e3181ae0a08 Winterstein, A. G., Soria-Saucedo, R., Gerhard, T., Correll, C. U., & Olfson, M. (2017). Differential risk of increasing psychotropic polypharmacy use in children diagnosed with ADHD as preschoolers. The Journal of Clinical Psychiatry , 78 (7), e744–e781. https://doi.org/10.4088/JCP.16m10884 World Health Organization. (n.d.). Medication Without Harm . World Health Organization. Retrieved May 12 (2025). from https://www.who.int/initiatives/medication-without-harm Wyatt, K. D., List, B., Brinkman, W. B., Lopez, P., Asi, G., Erwin, N., Wang, P., Domecq Garces, Z., Montori, J. P., V. M., & LeBlanc, A. (2015). Shared decision making in pediatrics: A systematic review and meta-analysis. Academic Pediatrics , 15 (6), 573–583. https://doi.org/10.1016/j.acap.2015.03.011 Zito, J. A. (2019). Polypharmacy Practice Patterns: Pharmacologic History Supports the Call for Research on Deprescribing Protocols. Presented at the 66th Annual American Academy of Child and Adolescent Psychiatry (AACAP) conference . Zito, J. M., Burcu, M., Ibe, A., Safer, D. J., & Magder, L. S. (2013). Antipsychotic use by medicaid-insured youths: impact of eligibility and psychiatric diagnosis across a decade. Psychiatric Services , 64 (3), 223–229. https://doi.org/10.1176/appi.ps.201200081 Zito, J. M., Zhu, Y., & Safer, D. J. (2021). Psychotropic polypharmacy in the US pediatric population: A methodologic critique and commentary. Frontiers in Psychiatry / Frontiers Research Foundation , 12 , 644741. https://doi.org/10.3389/fpsyt.2021.644741 Zuddas, A., Zanni, R., & Usala, T. (2011). Second generation antipsychotics (SGAs) for non-psychotic disorders in children and adolescents: a review of the randomized controlled studies. European Neuropsychopharmacology: The Journal of the European College of Neuropsychopharmacology , 21 (8), 600–620. https://doi.org/10.1016/j.euroneuro.2011.04.001 Additional Declarations Competing interest reported. Glyn Elwyn’s academic interests are focused on shared decision making and coproduction. He is the editor of the 4th edition of the Textbook of Shared Decision Making (Oxford University Press, 2025). He is the Founder and Director of &think LLC, which owns the registered trademark for Option Grid.TM He owns copyright in measures of shared decision making and care integration, namely collaboRATE, integRATE, Observer OPTION-5, and Observer OPTION-12. These measures are freely available. Ben Fehnert and James King are co-founders of Fora Health, the company responsible for developing and providing the app utilized in this study. All other authors report no disclosures. Supplementary Files AppendixS1.OptionGrid.pdf Appendix S1. Option Grid. AppendixS2.AntipsychoticDeprescribingProtocol.pdf Appendix S2. Deprescribing Protocol - Antipsychotics. AppendixS3.PolypharmacyDeprescribingProtocol.pdf Appendix S3. Deprescribing Protocol - Polypharmacy. AppendixS4.MedicationReactionsChecklist.pdf Appendix S4. Medication Reactions Checklist. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9201326","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":614288962,"identity":"e9c352ee-1d49-45a2-b7c4-5fabceec75d1","order_by":0,"name":"Erin R. 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McLaren","email":"","orcid":"","institution":"Dartmouth Health","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"L.","lastName":"McLaren","suffix":""},{"id":614288966,"identity":"5f1e8381-6b6d-4006-b8e8-3423626563ee","order_by":2,"name":"Hannah B. Leavitt","email":"","orcid":"","institution":"Dartmouth College","correspondingAuthor":false,"prefix":"","firstName":"Hannah","middleName":"B.","lastName":"Leavitt","suffix":""},{"id":614288969,"identity":"fbdbf6f5-2c32-4243-a182-3dde4bf551b7","order_by":3,"name":"Stephanie C. Acquilano","email":"","orcid":"","institution":"Dartmouth College","correspondingAuthor":false,"prefix":"","firstName":"Stephanie","middleName":"C.","lastName":"Acquilano","suffix":""},{"id":614288972,"identity":"0af6aee2-6519-416e-b79e-3ff8b11b3832","order_by":4,"name":"Rosemina Bazeghi","email":"","orcid":"","institution":"Dartmouth College","correspondingAuthor":false,"prefix":"","firstName":"Rosemina","middleName":"","lastName":"Bazeghi","suffix":""},{"id":614288973,"identity":"c2bf3dc7-87aa-4288-a166-f51a43afd59e","order_by":5,"name":"Stephanie Bizarri","email":"","orcid":"","institution":"Cayuga County Community Mental Health Center","correspondingAuthor":false,"prefix":"","firstName":"Stephanie","middleName":"","lastName":"Bizarri","suffix":""},{"id":614288978,"identity":"034745ac-2a47-47ce-b81c-634c92a7b6b1","order_by":6,"name":"Anthony Garami","email":"","orcid":"","institution":"Clinton County Mental Health Services","correspondingAuthor":false,"prefix":"","firstName":"Anthony","middleName":"","lastName":"Garami","suffix":""},{"id":614288983,"identity":"08085b7c-a35d-404c-b96b-939acc452722","order_by":7,"name":"James King","email":"","orcid":"","institution":"Fora Health Ltd","correspondingAuthor":false,"prefix":"","firstName":"James","middleName":"","lastName":"King","suffix":""},{"id":614288986,"identity":"f9e8f6d5-d89a-4354-b0de-7b9f98d995f7","order_by":8,"name":"Ben Fenhert","email":"","orcid":"","institution":"Fora Health Ltd","correspondingAuthor":false,"prefix":"","firstName":"Ben","middleName":"","lastName":"Fenhert","suffix":""},{"id":614288987,"identity":"6e655c63-35c6-472e-b9d2-c70c5581c51d","order_by":9,"name":"Glyn Elwyn","email":"","orcid":"","institution":"Dartmouth College","correspondingAuthor":false,"prefix":"","firstName":"Glyn","middleName":"","lastName":"Elwyn","suffix":""}],"badges":[],"createdAt":"2026-03-23 13:41:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9201326/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9201326/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105844562,"identity":"511423fe-82df-40a0-8ad1-3ec6d7b13469","added_by":"auto","created_at":"2026-03-31 17:33:26","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":168916,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCONSORT Diagram\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003edemonstrates the total number of participants eligible, recruited, consented/assented, and engaged in SDM treatment review during our study. This diagram also shows the number of participants who chose to deprescribe, remained undecided, or chose to not deprescribe, as well as the number of participants who completed each survey\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9201326/v1/59f2363eb0b5f75758a4f345.jpg"},{"id":105904845,"identity":"58cd9769-0518-4e6a-935b-826e31c4e6f6","added_by":"auto","created_at":"2026-04-01 10:10:48","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":68413,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDose Weighted Number of Medications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig. 2a.\u003c/strong\u003e Dose-weighted medication count by group over time showing mean medication counts at baseline, 18 weeks, and 30 weeks for participants who did not choose to deprescribe (blue line), participants who chose to deprescribe (red line), and the total sample (green line), demonstrating a decrease in medication count over time with a slightly greater reduction among participants who chose to deprescribe\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig. 2b.\u003c/strong\u003e Number of negative medication reactions by group over time showing mean number of reactions at first visit and last visit for participants who did not choose to deprescribe (blue line), participants who chose to deprescribe (red line), and the total sample (green line), demonstrating a decrease in negative medication reactions across all groups over time\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9201326/v1/e9d7fcc9118a247927f1953d.jpg"},{"id":105904431,"identity":"8098eaf0-7595-4bff-b60f-5f78284fe863","added_by":"auto","created_at":"2026-04-01 10:08:30","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":84983,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eClinician and Caregiver Functioning Results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig 3c.\u003c/strong\u003e Caregiver-rated youth impairment by group over time showing mean impairment ratings at baseline, 18 weeks, and 30 weeks for participants who did not choose to deprescribe (blue line), participants who chose to deprescribe (red line), and the total sample (green line), demonstrating reductions in impairment over time with convergence of group scores by 30 weeks\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig 3d. \u003c/strong\u003eCaregiver-rated youth aggression by group over time showing mean aggression ratings at baseline, 18 weeks, and 30 weeks for participants who did not choose to deprescribe (blue line), participants who chose to deprescribe (red line), and the total sample (green line), demonstrating increasing aggression over time in the non-deprescribing group and a decrease by 30 weeks in the deprescribing group\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9201326/v1/350cebea87bbae620ab02311.jpg"},{"id":105907527,"identity":"489921e6-c55f-4a07-a420-dbcea15ed55b","added_by":"auto","created_at":"2026-04-01 10:32:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2196638,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9201326/v1/03a181e8-af8f-439c-aeaa-45f9927ac0a6.pdf"},{"id":105905530,"identity":"0311fd97-dbb5-4a76-9b49-5b7e61ddbe58","added_by":"auto","created_at":"2026-04-01 10:12:40","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":459912,"visible":true,"origin":"","legend":"\u003cp\u003eAppendix S1. Option Grid.\u003c/p\u003e","description":"","filename":"AppendixS1.OptionGrid.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9201326/v1/eb1e408bd539483686df3ba8.pdf"},{"id":105844563,"identity":"952c71c8-b5c3-4541-a45d-2830e795ff8d","added_by":"auto","created_at":"2026-03-31 17:33:26","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":291260,"visible":true,"origin":"","legend":"\u003cp\u003eAppendix S2. Deprescribing Protocol - Antipsychotics.\u003c/p\u003e","description":"","filename":"AppendixS2.AntipsychoticDeprescribingProtocol.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9201326/v1/ade7705878c876b6269de25e.pdf"},{"id":105905234,"identity":"86f8fc84-193b-4953-84bb-1f87ade427c3","added_by":"auto","created_at":"2026-04-01 10:11:41","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":411145,"visible":true,"origin":"","legend":"\u003cp\u003eAppendix S3. Deprescribing Protocol - Polypharmacy.\u003c/p\u003e","description":"","filename":"AppendixS3.PolypharmacyDeprescribingProtocol.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9201326/v1/2b57f848b30564cf9b5cf66f.pdf"},{"id":105844566,"identity":"08293c00-5620-4d8e-8e47-888c353b19a6","added_by":"auto","created_at":"2026-03-31 17:33:26","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":57190,"visible":true,"origin":"","legend":"\u003cp\u003eAppendix S4. Medication Reactions Checklist.\u003c/p\u003e","description":"","filename":"AppendixS4.MedicationReactionsChecklist.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9201326/v1/50182f01a0a863f06619a583.pdf"}],"financialInterests":"Competing interest reported. Glyn Elwyn’s academic interests are focused on shared decision making and coproduction. He is the editor of the 4th edition of the Textbook of Shared Decision Making (Oxford University Press, 2025). He is the Founder and Director of \u0026think LLC, which owns the registered trademark for Option Grid.TM He owns copyright in measures of shared decision making and care integration, namely collaboRATE, integRATE, Observer OPTION-5, and Observer OPTION-12. These measures are freely available. Ben Fehnert and James King are co-founders of Fora Health, the company responsible for developing and providing the app utilized in this study. All other authors report no disclosures.","formattedTitle":"Deprescribing psychiatric medications in youth: A feasibility study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe use of off-label antipsychotics and psychiatric polypharmacy, defined here as three or more psychiatric medications, has increased internationally and among US children and adolescents, henceforth referred to as youth, over the past 20 years.(Chiang et al., 2024; Davis et al., 2021; Winterstein et al., 2017; J. M. Zito et al., 2021) An estimated 1.3 million youth in the US receive psychiatric polypharmacy or off-label antipsychotics.(Olfson et al., 2015; J. M. Zito et al., 2021) Youth also remain on these medications far longer than the clinical durations studied.(Crystal et al., 2016; J. M. Zito et al., 2013) Youth with social and developmental vulnerabilities, including those receiving Medicaid and those in foster care, have the highest rates of off-label antipsychotic use and polypharmacy.(Allen et al., 2018; Barnett et al., 2019; Crystal et al., 2016; Dosreis et al., 2011; Simmel et al., 2021; Zuddas et al., 2011) \u003c/p\u003e\n\u003cp\u003eSide effects reported for antipsychotics can include weight gain, metabolic abnormalities, neurocognitive impairments, sedation, tremor, somnolence, and restlessness.(Caccia, 2013; Cohen et al., 2012; Pillay et al., 2017; Zuddas et al., 2011) Long-term antipsychotic use in adults has given rise to obesity, diabetes, heart disease, cortical thinning, and impaired social functioning.(Andreasen et al., 2013) The recommended monitoring in youth occurs inconsistently.(AACAP, n.d.; Sanyal et al., 2024; Walkup \u0026amp; Work Group on Quality Issues, 2009) No studies have assessed the safety of psychiatric polypharmacy in youth. Moreover, caregivers are often unaware of the risks of psychiatric medications in youth, although side effects are their most frequent concern.(Barnett et al., 2019; Brinkman et al., 2011; McLaren et al., 2022)\u003c/p\u003e\n\u003cp\u003eCalls, both professional and societal, to reduce the off-label use of antipsychotics and polypharmacy in youth are increasing(M. Boland et al., 2024; Keeshin et al., 2020; Kutz, 2012; Morgan \u0026amp; Baker, 2024; World Health Organization, n.d.; J. A. Zito, 2019), public concern is growing (Assistant Secretary for Public Affairs (ASPA), 2025; Richtel \u0026amp; Flanagan, 2022), and caregivers and prescribing clinicians are increasingly willing to consider reducing these medications.(Barnett et al., 2020; McLaren et al., 2022)\u003c/p\u003e\n\u003cp\u003eThe term deprescribing describes the process of prescribing clinicians (henceforth referred to as clinicians) and patients working together to reduce or remove medications based on effectiveness, side effects, and patient preferences.(Goldberg et al., 2025; Gupta et al., 2019) Deprescribing has been primarily described and studied in the elderly, with results demonstrating reduced side effects, fewer drug interactions, and improved health, mental health, and quality of life (Davies et al., 2020; Mohamed et al., 2020; Nieder et al., 2017)Within child psychiatry, studies of children in residential settings have demonstrated safe deprescribing of antipsychotics and polypharmacy, leading to less aggression, less use of restraints, and lower costs.(Bellonci et al., 2013; Connor \u0026amp; McLaughlin, 2005; Huefner et al., 2014; van Wattum et al., 2013) A body of literature has also emerged around deprescribing antidepressants in youth, with attention to individualized approaches.(Stimpfl et al., 2025)\u003c/p\u003e\n\u003cp\u003eShared decision making (SDM) is an approach where clinicians and patients collaborate to tailor treatment based on both clinical evidence and the patient\u0026apos;s preferences.(Barnett et al., 2018; L. Boland et al., 2019; \u003cem\u003eMaking Shared Decision-Making A Reality\u003c/em\u003e, n.d., \u003cem\u003ePatients\u0026rsquo; Preferences Matter\u003c/em\u003e, n.d.; Wyatt et al., 2015) For youth, SDM requires a triadic process between the youth, caregivers, and clinicians. Although very few studies have examined shared decision making (SDM) in child psychiatry, there is evidence that youth and their caregivers want their voices heard.(Barnett et al., 2019; Brinkman et al., 2013; Pillen et al., 2024)\u003c/p\u003e\n\u003cp\u003eDespite the need to engage youth and their caregivers in decisions about high-risk psychiatric medication and provide structured guidance to clinicians, there are no published structured deprescribing protocols available to support clinicians caring for outpatient youth. To address this gap, we aimed to develop and test the feasibility of an intervention that facilitates SDM between youth, caregivers, and clinicians and provides structured deprescribing guidance to clinicians caring for youth in outpatient settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eProcedures\u003c/h2\u003e \u003cp\u003eOur evaluation adopted a mixed-methods approach, collecting data from online surveys, electronic health records (EHR), a smartphone app, and by interviewing clinicians and caregivers. We recruited clinicians and youth/caregiver dyads from two urban outpatient community mental health centers in New York between December 2023 and April 2024. Both clinics served Medicaid populations and accepted private insurance, offering a range of psychiatric, counseling, and case management services. Prescribing clinicians and clinic administrators identified all potentially eligible caregivers and youth from their client lists using electronic health record data. At the next clinic visit for each of the identified youth, clinicians briefly explained the study and obtained permission for the research team to talk with them. Prospective caregivers and youth participants were then contacted by a research assistant who provided copies of the informed consent and assent documents and conducted the consent discussion. Caregivers were compensated \u003cspan\u003e$\u003c/span\u003e30 for taking part in the consent discussion and \u003cspan\u003e$\u003c/span\u003e50 for each of the three research assessments completed. Those who completed an interview received an additional \u003cspan\u003e$\u003c/span\u003e75. This study was overseen by a single IRB, the Biomedical Research Alliance of New York (BRANY), and conducted in accordance with the Declaration of Helsinki as revised in 2024. Caregivers and youth provided written informed consent and written (ages 12\u0026ndash;17 years) or verbal (ages 6\u0026ndash;11 years) assent prior to engaging in any study activities. Clinicians provided written informed consent in advance of the qualitative interviews.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eInclusion criteria\u003c/h2\u003e \u003cp\u003eEligible youth were: (a) aged 6\u0026ndash;17 years, (b) prescribed psychiatric polypharmacy (3 or more concurrent medications) or an antipsychotic off-label for at least 3 months, and (c) had no hospitalizations, emergency room visits, or major life events (i.e., moving, changing schools) in the previous 3 months. Eligible caregivers (parents or guardians) were: (a) 18 years or older, (b) capable of providing informed consent, and (c) fluent in English. Eligible clinicians: (a) provided care to youth at one of the clinics and (b) were fully licensed to prescribe medications.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cp\u003eYouth were considered ineligible if they: (a) had an acute crisis, (b) had a diagnosed substance use disorder, (c) were pregnant, or (d) were prescribed an antipsychotic for a condition approved by the FDA, such as a psychotic disorder, bipolar disorder, autism spectrum disorder with irritability/aggression, or Tourette\u0026rsquo;s disorder.\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eThe clinical research team developed a preliminary version of the intervention and accompanying tools and manual. Prior to study launch, the tools and manual were revised in partnership with our Advisory Group, comprising two child clinical prescribers and two parents of youth who had received psychiatric polypharmacy and off-label antipsychotics in the past.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePhase 1. Shared decision making treatment review phase (~\u0026thinsp;4 weeks)\u003c/h2\u003e \u003cp\u003eThe intervention began with a collaborative treatment review during which the triad (clinician, caregiver, and youth) discussed the youth\u0026rsquo;s medications and made a shared decision regarding whether to try deprescribing a medication. This was completed in 1 or 2 sessions over the course of about 4 weeks. The triad considered whether each medication was improving symptoms, causing side effects, and still necessary. The research team did not impose any standards for which medication the triad might choose to try to deprescribe; decisions were individualized through the SDM process. SDM was supported by two tools: 1) a caregiver-facing Option Grid conversation aid (see Appendix S1), and 2) a smartphone-based chatbot app for caregivers (with a web portal for clinicians). The Option Grid supported SDM by describing five options, behavioral therapy plus four classes of medications, comparing the likely risks and benefits of each and providing plain language answers to frequently asked questions.(Barnett et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) The chatbot app contained the Option Grid content, other resource materials, and a treatment plan section that allowed caregivers to review various options, record their preferences, and leave comments that were viewable by clinicians in the web portal. The app also enabled caregivers to complete weekly health check-ins and an assessment of SDM.(Elwyn et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) Phase 1 ended with a shared decision whether or not to try deprescribing.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePhase 2. Deprescribing and monitoring medications phase (~ 14 weeks)\u003c/h3\u003e\n\u003cp\u003eThis phase was supported by a clinician-facing deprescribing protocol that facilitated tapering schedules and monitoring (see Appendix S2 and S3). Families who elected not to try deprescribing continued with their psychiatric care as usual. We modeled the protocol on existing structured guidance for deprescribing medications in the elderly (Bjerre et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) and on broad recommendations made by expert clinicians for children (Bellonci \u0026amp; Carlson, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; de Kuijper et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Lohr, n.d.; Reeve et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Scott et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Protocol development involved multiple iterations, including consultation with 14 residents and fellows in psychiatry, tests of clinical utility by colleagues, and multiple changes as a result of feedback. When 9 pediatric clinicians confirmed that the protocol was practical, feasible, and usable, we completed a pilot test with 4 youth (age 6\u0026ndash;17 years) taking atypical antipsychotics. Their medications were reduced or eliminated over a few months without adverse events. We then expanded the protocol to support deprescribing for polypharmacy, again based on existing guidance (Bellonci et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Bellonci \u0026amp; Carlson, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Connor \u0026amp; McLaughlin, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Huefner et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Lohr, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Reeve et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Scott et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), using feedback from 10 child psychiatry prescribers.\u003c/p\u003e \u003cp\u003e As a research team, we provided 3 hours of training to participating clinicians, including didactic, discussion, and role plays. After describing the study, we discussed the challenges of providing psychiatric care to youth, described SDM, simulated the use of the Option Grid conversation aid, and reviewed the deprescribing protocol. We reinforced fidelity to the intervention through monthly consultation with the research team child psychiatrist/co-principal investigator (JM).\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eWe conducted online caregiver assessments at baseline, 18, and 30 weeks after the first study visit. We collected medication reaction checklists and safety events from clinicians during clinic visits. We also obtained data from medical records, the smartphone app, and qualitative interviews with participants (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eMeasures, Sources \u0026amp; Assessment Schedule\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSource\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of Items\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eResponse Scale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEstablished Psychometrics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003e\u003cem\u003eWeeks 1\u0026ndash;18\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePost-\u003c/p\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003e\u003cem\u003eWeek 18\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFollow-up\u003c/p\u003e \u003cp\u003e\u003cem\u003eWeek 30\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003eOnline Assessments\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCaregiver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYouth impairment (CIS-P)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCaregiver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYouth aggression (MOAS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCaregiver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvolvement in decisions (M-PICS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCaregiver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIllness severity \u0026amp; improvement (CGI-S \u0026amp; CGI-I)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYouth impairment (CIS-Y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYouth\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedication reactions (MRC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes / No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e✓ (each visit)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSafety (adverse events)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e✓ (each visit)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eElectronic Health Record\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnoses, date of birth, insurance payor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinic Staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedications \u0026amp; dosages\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinic Staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e✓ (each visit)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinic visit type \u0026amp; date\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinic Staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e✓ (each visit)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSmartphone App\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuality of SDM (collaboRATE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCaregiver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e✓\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e✓ (wks 4, 8, \u0026amp; 12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKey areas of youth functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCaregiver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e✓ (weekly)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQualitative Interviews\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntervention feasibility, acceptability, benefits, \u0026amp; ways to improve; opinions about medications, shared decision making, deprescribing \u0026amp; conversation aid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCaregiver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNarrative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003eCaregivers were interviewed between weeks 18 and 30 (with one exception, one interview was 14 days after week 30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntervention feasibility, acceptability, benefits, \u0026amp; ways to improve; effectiveness of training \u0026amp; support; opinions about medications, shared decision making, deprescribing \u0026amp; structured deprescribing protocol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNarrative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003eClinicians were interviewed after all their participants had completed the study\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eNote. n/a\u0026thinsp;=\u0026thinsp;not applicable;CIS-P\u0026thinsp;=\u0026thinsp;Columbia Impairment Scale, parent version; MOAS\u0026thinsp;=\u0026thinsp;Modified Overt Aggression Scale; M-PICS\u0026thinsp;=\u0026thinsp;Modified Perceived Involvement in Care Scale; CGI-S\u0026thinsp;=\u0026thinsp;Clinical Global Impression - Severity; CGI-I\u0026thinsp;=\u0026thinsp;Clinical Global Impression - Improvement; CIS-Y\u0026thinsp;=\u0026thinsp;Columbia Impairment Scale, youth version; SDM\u0026thinsp;=\u0026thinsp;shared decision making; wks\u0026thinsp;=\u0026thinsp;weeks.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003csup\u003ea\u003c/sup\u003eYouth ages 12 and older were invited to complete the CIS-Y at each assessment point.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003csup\u003eb\u003c/sup\u003e60 possible medication reactions across 11 body systems based on the Psychotropic Medications Monitoring Checklist (PMMC)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eOnline assessments\u003c/h2\u003e \u003cp\u003eCaregivers and clinicians completed online surveys through a HIPAA-compliant REDCap system. We used the Columbia Impairment Scale for caregivers and youth aged 12 and older(Attell et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Cleverley et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Singer et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) and the Clinical Global Impression severity (CGI-S) and improvement (CGI-I) clinician rating scales(Attell et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Busner \u0026amp; Targum, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2007\u003c/span\u003e) to assess youth functioning. We measured youth aggression using the Modified Overt Aggression Scale (MOAS)(Kay et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e1988\u003c/span\u003e) and the extent to which caregivers felt involved in clinical decisions using the Modified Perceived Involvement in Care Scale (M-PICS)((Smith et al., \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) These online assessments were collected at baseline and 18 and 30 week follow up.\u003c/p\u003e \u003cp\u003eWe created a simple checklist, the Medication Reactions Checklist (MRC), with 60 negative medication reactions organized by 11 body systems (included as Appendix S4). These 60 reactions were taken from the Psychotropic Medication Monitoring Checklist (PMMC),(Ninan et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) which is widely used in clinical trials, but often considered too long and complicated for use in routine settings. We chose the terminology of \u0026ldquo;medication reactions\u0026rdquo; over the more widely used \u0026ldquo;side effects\u0026rdquo; because medication-related issues can encompass not only side effects but also withdrawal effects, medication interactions, or relapse in symptoms. Clinicians completed the MRC with caregivers and youth at each study visit, and probed for adverse events (e.g., hospitalizations, behavioral escalations). After the visit, clinicians then indicated whether the identified medication reactions were likely related to the study using their clinical judgment and knowledge of the youth\u0026rsquo;s history and current life experiences. Clinicians also reported any adverse events, including suicidality, to the research team.\u003c/p\u003e \u003cp\u003e \u003cb\u003e[insert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cb\u003ehere]\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMedical records\u003c/h2\u003e \u003cp\u003eSite staff extracted the following data from the medical record: psychiatric diagnoses, date of birth, medications and dosages (used to calculate dose-weighted medication count), clinic visit types and dates, insurance coverage, and decision made after the SDM treatment review.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSmartphone app data\u003c/h2\u003e \u003cp\u003eWe collected data about the caregivers\u0026rsquo; use of the app, including account activation, page visits, activities completed and dates of app usage. Caregivers were asked to complete two brief measures in the app: 1) a caregiver-reported level of perceived shared decision making (collaboRATE),(Barr et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Elwyn et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; \u003cem\u003eScoring collaboRATE\u003c/em\u003e, n.d.) and 2) health/functioning in six key areas (called health check-ins). We created the health check-ins rating scale to track general functioning during the study; caregivers were prompted weekly to rate how much their youth had been affected in the areas of mood, behavior, sleep, ability to wake up/stay awake in the morning, ability to stay alert throughout the day, and appetite.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eQualitative interviews\u003c/h2\u003e \u003cp\u003eWe purposely invited 21 caregivers who had agreed to be interviewed and who differed in their clinician, clinic, decisions to deprescribe, app use, and caregiver and youth sex. We invited all 5 participating clinicians for interviews. Our interview guide covered the following topics: reactions to the interventions, the use of SDM, the Option Grid, the deprescribing protocol, smartphone app and web portal, and whether they would recommend changes to be made in future studies. We asked a researcher who was not part of the core study team (RB) to conduct the interviews. We followed the COnsolidated criteria for REporting Qualitative research standards of reporting qualitative research (COREQ) (Tong et al., \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eAnalyses\u003c/h2\u003e \u003cp\u003eBecause of our small sample size, we did not have power to conduct any statistical tests of significance. Given the primary objective of the study was to understand the feasibility of the intervention and study procedures, we conducted descriptive statistics and examined patterns over time in our quantitative data, and thematic analyses on our qualitative data. Our results are reported as frequencies and percentages for categorical data, means and standard deviations for continuous data, and most common themes from our qualitative interviews.\u003c/p\u003e \u003cp\u003eWe calculated dose-weighted medications instead of a simple medication count to reflect reductions in dose. The number of dose-weighted medications at each follow-up point was calculated as a sum of the proportion of the current dose of each medication compared to the sum of the baseline doses of those medications. For example, if a participant was taking 100 mgs of trazodone and 25 mgs of zoloft daily at baseline and 50 mgs of trazodone and 25 mgs of zoloft daily at 18-week follow-up, the dose-weighted number of medications at follow-up would be 1.5 (whereas a straight count of medications at follow-up would be 2).\u003c/p\u003e \u003cp\u003eParticipants had varying numbers of visits during the study, based on clinical need, which resulted in differing numbers of clinician-rated medication reaction checklists (MRCs). To eliminate the problem of unequal numbers of completed MRCs across participants and to reflect changes in negative medication reactions from study initiation to final follow-up assessment, we compared each participant\u0026rsquo;s first completed MRC to their last MRC.\u003c/p\u003e \u003cp\u003eWe adopted the Practical Thematic Analysis approach to qualitative interviews.(Saunders et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) EB and RB read all transcripts, created a code book, conducted double-coding on 8 transcripts before individually coding the rest, and independently drafted a set of themes based on the coding. A third researcher (HL) facilitated a collaborative theming process to finalize the themes and these were reviewed by all authors for approval.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eFeasibility\u003c/h2\u003e \u003cp\u003eWe identified 39 eligible youth/caregiver dyads, enrolled 31, and provided the intervention to 29. Of those 29, 20 (69%) completed the 18-week follow-up assessment and 15 (52%) completed the 30-week follow-up assessment. See Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for details. For qualitative interviews, we approached 21 caregivers and all 5 clinicians; 10 caregivers (48%; 2 declined, 9 could not be reached) and 4 clinicians agreed to participate (80%; 1 declined).\u003c/p\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, most of the participants were White, non-Hispanic, and covered by public insurance; 85% of caregivers were female and 63% of youth were male. Mean caregiver and youth ages were 40 and 12 years, respectively. Youth received a mean of 3.6 concurrent medications and the most common diagnosis was attention deficit hyperactivity disorder (ADHD); 66% of youth were taking an antipsychotic medication (either alone or as part of polypharmacy). The majority of clinicians were female, White, and non-Hispanic, providing care to both youth and adults. Demographics of caregivers, youth, and clinicians who were interviewed were representative of the full sample.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of Caregivers, Youth and Clinicians\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregivers \u003cem\u003e(n\u0026thinsp;=\u0026thinsp;31)\u003c/em\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (female), \u003cem\u003en\u0026thinsp;=\u0026thinsp;27\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace (White), \u003cem\u003en\u0026thinsp;=\u0026thinsp;27\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity (not Hispanic), \u003cem\u003en\u0026thinsp;=\u0026thinsp;26\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status (married), \u003cem\u003en\u0026thinsp;=\u0026thinsp;27\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level, \u003cem\u003en\u0026thinsp;=\u0026thinsp;26\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school or less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSome college or 2-year degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4-year college or graduate degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelationship to child (mother/step-mother), \u003cem\u003en\u0026thinsp;=\u0026thinsp;27\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (in years), \u003cem\u003en\u0026thinsp;=\u0026thinsp;25\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChildren \u003cem\u003e(n\u0026thinsp;=\u0026thinsp;31)\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (male), \u003cem\u003en\u0026thinsp;=\u0026thinsp;27\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace (White), \u003cem\u003en\u0026thinsp;=\u0026thinsp;27\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity (not Hispanic), \u003cem\u003en\u0026thinsp;=\u0026thinsp;27\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (in years), \u003cem\u003en\u0026thinsp;=\u0026thinsp;23\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary insurance (public/Medicaid) \u003cem\u003e(n\u0026thinsp;=\u0026thinsp;29)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychiatric medications \u003cem\u003e(n\u0026thinsp;=\u0026thinsp;29)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal number\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolypharmacy\u003csup\u003ec\u003c/sup\u003e (no antipsychotic)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolypharmacy\u003csup\u003ec\u003c/sup\u003e with an antipsychotic or antipsychotic only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMost common diagnoses\u003csup\u003eb,d\u003c/sup\u003e \u003cem\u003e(n\u0026thinsp;=\u0026thinsp;29)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttention deficit hyperactivity disorder (ADHD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisruptive, Impulse Control \u0026amp; Conduct Disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety Disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinicians \u003cem\u003e(n\u0026thinsp;=\u0026thinsp;5)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace (White)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity (not Hispanic)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient population (pediatric \u0026amp; adult)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (in years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears in practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eFour caregiver participants did not complete the baseline survey with caregiver demographics.\u003c/p\u003e \u003cp\u003e\u003csup\u003eb\u003c/sup\u003eFour caregiver participants did not complete the baseline survey with youth demographics; an additional 4 caregivers did not complete youth age. In addition, EMR data from the 2 participants who dropped out before the intervention were not available.\u003c/p\u003e \u003cp\u003e\u003csup\u003ec\u003c/sup\u003ePolypharmacy is defined as 3 or more concurrent medications.\u003c/p\u003e \u003cp\u003e\u003csup\u003ed\u003c/sup\u003eTotals exceed 100% because most participants had more than one diagnosis.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e[insert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cb\u003ehere]\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAll caregivers were invited to use the smartphone chatbot application and associated resources. Of the 29 who received the intervention, 22 (76%) activated their app account. Caregivers most commonly used the treatment section, where options, preferences, and plans could be reviewed and comments made (62%, n\u0026thinsp;=\u0026thinsp;18 of 29), while only 21% (n\u0026thinsp;=\u0026thinsp;6 of 29) accessed the resources section. The collaboRATE survey was also embedded within the app. Response rates were too low to run analyses; only 10 of 29 (34%) caregivers completed at least one survey.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e demonstrates the total number of participants eligible, recruited, consented/assented, and engaged in SDM treatment review during our study. This diagram also shows the number of participants who chose to deprescribe, remained undecided, or chose to not deprescribe, as well as the number of participants who completed each survey\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eProcess outcomes\u003c/h2\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003eChoice to deprescribe\u003c/h2\u003e \u003cp\u003eThirteen (45%) of the 29 participants chose to try deprescribing a medication; 12 (41%) did not choose to deprescribe, and 4 (14%) remained undecided. These 4 were included with the 12 who did not choose to deprescribe for the comparisons described below. Of the 13 who began deprescribing, 7 discontinued the medication entirely, 4 reduced dose (3 by 50% or more) and remained on the lower dose, and 5 chose to deprescribe a second medication. Two of the 13 stopped deprescribing and returned to their original dose. The following medications were chosen for deprescribing: risperidone, buspirone HCl, guanfacine, prazosin, fluoxetine, clonidine, aripiprazole, citalopram, amphetamine/dextroamphetamine, lurasidone, trazodone, and cyproheptadine. Five youth then chose to deprescribe a second medication, which included: amphetamine/ dextroamphetamine, clonidine, risperidone, hydroxyzine, and guanfacine. The two youth who stopped deprescribing and returned to their original dose were receiving cyproheptadine and trazodone. For the former, cyproheptadine was being taken to stimulate appetite due to stimulant use, and the youth\u0026rsquo;s appetite reduced when they stopped the periactin. For the latter, trazodone was being taken to help with sleep, and the youth\u0026rsquo;s sleeping difficulties returned.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eCaregiver involvement in decisions\u003c/h2\u003e \u003cp\u003eCaregivers reported moderate levels of perceived involvement in decisions related to their child\u0026rsquo;s psychiatric care, and these reports were relatively stable across time points. Patterns in these perceptions were similar for the full sample and by group (chose vs. did not choose to deprescribe).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003eDose-weighted number of medications\u003c/h2\u003e \u003cp\u003eFor the full sample (N\u0026thinsp;=\u0026thinsp;29), the average number of dose-weighted medications reduced from 3.6 (SD\u0026thinsp;=\u0026thinsp;1.09) at baseline to 3.1 (SD\u0026thinsp;=\u0026thinsp;1.35) at 30-week follow-up. In group comparisons, there was a greater reduction in dose-weighted medications for those who chose to deprescribe (3.9 at baseline to 2.9 at 30-week follow-up) than for those who did not choose to deprescribe (from 3.4 at baseline to 3.2 at 30-week follow-up). See Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eYouth Outcomes by Group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"19\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c18\" colnum=\"18\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c19\" colnum=\"19\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e \u003cp\u003eTotal Sample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c13\" namest=\"c8\"\u003e \u003cp\u003eChose to Deprescribe\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c19\" namest=\"c14\"\u003e \u003cp\u003eDid Not Choose to Deprescribe\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c13\" namest=\"c8\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c19\" namest=\"c14\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c19\" namest=\"c18\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMeasure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003eM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cb\u003eM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e\u003cb\u003eM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e\u003cb\u003eM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e\u003cb\u003eM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDose-Weighted Medications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e1.09\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e1.30\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e1.35\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003e1.28\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003e1.29\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e2.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cem\u003e1.41\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e3.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e\u003cem\u003e0.89\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e3.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e\u003cem\u003e1.35\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e3.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e\u003cem\u003e1.32\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNegative Medication Reactions\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e1.62\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e0.38\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003e2.21\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003e0.48\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e\u003cem\u003e0.89\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e\u003cem\u003e0.00\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFunctioning\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYouth impairment (CIS-P)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e9.8\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e11.5\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e11.4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e20.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003e10.79\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e23.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003e12.89\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e23.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cem\u003e12.27\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e27.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e\u003cem\u003e7.70\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e25.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e\u003cem\u003e10.64\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e23.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e\u003cem\u003e11.13\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYouth aggression (MOAS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e7.63\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e10.25\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e10.14\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003e7.32\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e13.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003e10.58\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cem\u003e7.81\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e\u003cem\u003e7.86\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e12.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e\u003cem\u003e10.43\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e14.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e\u003cem\u003e12.72\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYouth impairment (CIS-Y)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e12.54\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e11.93\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e12.11\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIllness severity (CGI-S)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e0.8\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e0.8\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e1.2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003e0.71\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003e0.78\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cem\u003e0.85\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e\u003cem\u003e0.83\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e\u003cem\u003e0.91\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e\u003cem\u003e1.42\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIllness improvement\u003csup\u003ec\u003c/sup\u003e (CGI-I)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e0.83\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e1.07\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003e0.95\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cem\u003e1.01\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e\u003cem\u003e0.74\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e\u003cem\u003e1.10\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"19\" nameend=\"c19\" namest=\"c1\"\u003e \u003cp\u003eNote. T0\u0026thinsp;=\u0026thinsp;baseline; T1\u0026thinsp;=\u0026thinsp;18 weeks post first study visit; T2\u0026thinsp;=\u0026thinsp;30 weeks post first study visit; M\u0026thinsp;=\u0026thinsp;mean; SD\u0026thinsp;=\u0026thinsp;standard deviation; CIS-P\u0026thinsp;=\u0026thinsp;Columbia Impairment Scale, parent version; MOAS\u0026thinsp;=\u0026thinsp;Modified Overt Aggression Scale; CIS-Y\u0026thinsp;=\u0026thinsp;Columbia Impairment Scale, youth version; CGI-S\u0026thinsp;=\u0026thinsp;Clinical Global Impression - Severity; CGI-I\u0026thinsp;=\u0026thinsp;Clinical Global Impression - Improvement. For all functioning measures, higher scores are worse (e.g., higher impairment, aggression, illness severity, and less improvement).\u003c/p\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Negative medication reactions checklists were completed by the clinician at each clinic visit during the intervention period. Participants had a varying number of visits during the study, so we compared the first checklist completed to the last checklist completed. T0\u0026thinsp;=\u0026thinsp;first medication checklist completed, T1\u0026thinsp;=\u0026thinsp;last checklist completed, T2\u0026thinsp;=\u0026thinsp;not applicable.\u003c/p\u003e \u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Only 17 youth completed the CIS-Y at baseline, 12 at 18 weeks, and 8 at 30 weeks. Sample sizes when split into decision groups are too small to display.\u003c/p\u003e \u003cp\u003e\u003csup\u003ec\u003c/sup\u003e There is no improvement rating at T0 because there is no previous rating with which to compare.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eNegative medication reactions\u003c/h2\u003e \u003cp\u003eFor the full sample, the average number of negative medication reactions reduced from 0.9 (SD\u0026thinsp;=\u0026thinsp;1.69) on the initial checklist to 0.2 (SD\u0026thinsp;=\u0026thinsp;0.38) on the final checklist. Those who chose to deprescribe showed a greater reduction in negative medication reactions (from 1.3 to 0.3) compared to those who did not choose to deprescribe (0.6 and 0.0, respectively).\u003c/p\u003e \u003cp\u003e \u003cb\u003e[insert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cb\u003ehere]\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. \u003cb\u003eDose Weighted Number of Medications\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea. Dose-weighted medication count by group over time showing mean medication counts at baseline, 18 weeks, and 30 weeks for participants who did not choose to deprescribe (blue line), participants who chose to deprescribe (red line), and the total sample (green line), demonstrating a decrease in medication count over time with a slightly greater reduction among participants who chose to deprescribe\u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb. Number of negative medication reactions by group over time showing mean number of reactions at first visit and last visit for participants who did not choose to deprescribe (blue line), participants who chose to deprescribe (red line), and the total sample (green line), demonstrating a decrease in negative medication reactions across all groups over time\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eSafety\u003c/h2\u003e \u003cp\u003eThere were no study-related serious adverse events or behavioral escalations reported by participants or clinicians. As reported above, the number of negative medication reactions reduced for all participants. The study clinicians judged that for seven participants, the identified negative medication reactions may have been related to study deprescribing. The reactions were minor and included: feeling depressed, trouble sleeping, decreased appetite, agitation/irritability, hyperactivity/impulsivity, problems focusing, and feeling jittery. Five participants tolerated the reactions well and continued to deprescribe; two decided to stop deprescribing due to trouble sleeping (trazadone) and decreased appetite (cyproheptadine) and return to their original dose.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eFunctioning\u003c/h2\u003e \u003cp\u003eFor the full sample (N\u0026thinsp;=\u0026thinsp;29), outcome measures related to youth functional impairment, illness severity and improvement appeared similar across time points. These patterns were also true when comparing those who chose to deprescribe (n\u0026thinsp;=\u0026thinsp;13) with those who did not choose to deprescribe (n\u0026thinsp;=\u0026thinsp;16). Aggression ratings remained fairly stable for the full sample and those choosing to deprescribe, but trended towards getting worse for those choosing \u003cem\u003enot\u003c/em\u003e to deprescribe. See Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003e[insert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cb\u003ehere]\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e. \u003cb\u003eClinician and Caregiver Functioning Results\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003ea Clinician-rated illness severity by group over time showing mean severity ratings at baseline, 18 weeks, and 30 weeks for participants who did not choose to deprescribe (blue line), participants who chose to deprescribe (red line), and the total sample (green line), demonstrating a decrease in severity across time points with slightly greater reductions in the non-deprescribing group by 30 weeks\u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003eb. Clinician-rated improvement by group over time showing mean improvement ratings at 18 weeks and 30 weeks for participants who did not choose to deprescribe (blue line), participants who chose to deprescribe (red line), and the total sample (green line), demonstrating modest declines in improvement ratings over time with similar trajectories across groups\u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003ec. Caregiver-rated youth impairment Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003ed. Caregiver-rated youth aggression\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003ed. Caregiver-rated youth aggression by group over time showing mean aggression ratings at baseline, 18 weeks, and 30 weeks for participants who did not choose to deprescribe (blue line), participants who chose to deprescribe (red line), and the total sample (green line), demonstrating increasing aggression over time in the non-deprescribing group and a decrease by 30 weeks in the deprescribing group\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eQualitative outcomes\u003c/h2\u003e \u003cp\u003eWe identified six caregiver and five clinician themes. Several themes converged between groups, including fit between the intervention and prior beliefs; the need for strong relationships between youth, caregivers, and clinicians; the importance of a triadic SDM process; increased caregiver knowledge about medications due to the intervention; and a positive research process. See Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e for exemplar quotes from caregivers and clinicians.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCaregiver Themes and Illustrative Quotes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSupporting Quotes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregivers\u0026rsquo; views aligned with the goals of SDM and treatment optimization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;I think it just made me a little bit more aware of looking at other possible medications and trying to be more of an advocate for her\u0026hellip;trying to make sure that she realizes this is not something we're doing to her. It's something we're doing with her.\u0026rdquo; Caregiver 6\u003c/p\u003e \u003cp\u003e\u0026ldquo;At first, I was really nervous\u0026hellip;after we did it, and we ran into a hitch with the first time, so we lowered a different medication. Now she's lowered [a medication] down to a lot, and she's even off some medications.\u0026rdquo; Caregiver 2\u003c/p\u003e \u003cp\u003e\u0026ldquo;Just the open line of communication is huge. Paying attention to the signs and symptoms that the kids are having, concerns that you might be having, reasons as to why you would want to change or lower. I mean, there's a lot that goes into that kind of decision-making.\u0026rdquo;\u0026nbsp;Caregiver 5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExisting positive relationships with clinicians influenced decisions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;We have considered, and we've been working with our provider to lower [medications] a little bit. We will take a medicine and say, \u0026lsquo;Is this the time to start lowering it?\u0026rsquo; You seem to be doing a good job...\u0026rdquo;\u0026nbsp; So that's something our prescriber has been doing all along. She's really been working hard at that.\u0026ldquo; Caregiver 4\u003c/p\u003e \u003cp\u003e\u0026ldquo;We've built a good relationship with her [clinician]. My daughter trusts her. I trust her, and it's been a really good experience with her.\u0026rdquo; Caregiver 3\u003c/p\u003e \u003cp\u003e\u0026ldquo;I felt pretty involved. I mean, not so much as choosing the med because she [clinician] made the recommendations\u0026hellip; but she involved us\u0026nbsp;in educating us on the medication and the side effects and everything else.\u0026rdquo; Caregiver 9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe collaborative team-based approach, inclusive of the youth, was valued\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;We've kind of always, in the past, kind of always been blindly doing what the doctor said. Partly because, in the past, we didn't really have a say. Some of these kids were foster kids, and it's like, \u0026lsquo;Well, you do what we tell you to, whether you like it or not.\u0026rsquo; So being able to have this conversation with the doctor is just very freeing and liberating. I love being able to be a part of that discussion.\u0026rdquo; Caregiver 6\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think that they have to look at everything\u0026hellip;to come to a team decision with the provider and the child and the parent all together\u0026hellip; the provider has some insight of seeing things sometimes that we don't see\u0026hellip; but the parent can be there to tell the provider what's going on\u0026hellip;because the provider's not in the home.\u0026rdquo; Caregiver 9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregivers reported increased knowledge and empowerment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;I'm actually very grateful for the study because had we not gotten involved, I would not have known that about the risperidone [side effects].\u0026rdquo; Caregiver 6\u003c/p\u003e \u003cp\u003e\u0026ldquo;I do feel like I learned a lot more about my daughter's medications than anything else and different options that are out there to help proceed with certain situations.\u0026rdquo; Caregiver 1\u003c/p\u003e \u003cp\u003e\u0026ldquo;I definitely learned a lot more details in depth with the medications and how they function and work together. And also that open line of communication more\u0026ndash; I spoke up before, my concerns, but I definitely opened up more to say, \u0026lsquo;Hey, this was working, but I don't think this is working anymore, and I want to try something else.\u0026rsquo;\u0026rdquo; Caregiver 7\u003c/p\u003e \u003cp\u003e\u0026ldquo;I found that [Option Grid]incredibly helpful. There were a couple of things I didn't know. I mean, we've been a therapeutic foster home for 15 years, so we have experience with a lot of medications, but some of that I didn't know, so I found it incredibly helpful.\u0026rdquo; Caregiver 6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregivers reported positive outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;I think it's a really great project that's very beneficial and helpful overall\u0026hellip;it's more of a team effort all the way around to benefit the child and the care so a parent and provider can work together.\u0026rdquo; Caregiver 7\u003c/p\u003e \u003cp\u003e\u0026ldquo;When she first started trying to come off the Abilify, she got very aggressive. So he [clinician] put it back up, and then he stopped the Buspirone. So that helped, and then she was off Doxepine next, and then we just cut the Abilify, and she's doing very well with it.\u0026rdquo;\u0026nbsp;Caregiver 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregivers were positive about the research processes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;People were very attentive to our time schedule, and they were very\u0026ndash; explained everything about the process of the survey and the questioning and very upfront. And I never felt like we were forced into doing anything. And my daughter felt very comfortable when she talked to everyone.\u0026rdquo; Caregiver 9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eCaregivers\u003c/h2\u003e \u003cp\u003e \u003cb\u003eCaregivers\u0026rsquo; views aligned with the goals of SDM and treatment optimization.\u003c/b\u003e All of the caregivers interviewed felt the study\u0026rsquo;s approach to medications aligned with their beliefs about how decisions should be made and about the use of psychotropic medication for their youth. They preferred a \u0026ldquo;less is more\u0026rdquo; approach: \u0026ldquo;\u003cem\u003eI don't want him to take all these medications. I want a root cause as to what's actually wrong with him\u003c/em\u003e\u0026rdquo; (Caregiver 3). Many reported having anxiety about the initiation of medication: \u0026ldquo;\u003cem\u003eMy biggest concern with any medication, really, is the side effects\u0026hellip;\u003c/em\u003e\u0026rdquo; (Caregiver 7). However, caregivers had mixed reactions when clinicians suggested deprescribing. Some had already considered it; for others, the idea was new: \u0026ldquo;\u003cem\u003eNo, I never considered it. I thought she would always be on all the meds the rest of her life\u003c/em\u003e\u0026rdquo; (Caregiver 2). Some admitted anxiety about the possibility. Many were pleased because it addressed their concerns about the side effects or allowed for more individualized care.\u003c/p\u003e \u003cp\u003e \u003cb\u003eExisting positive relationships with clinicians influenced decisions.\u003c/b\u003e Collaborative and trusting relationships fostered confidence in medication decisions and helped families feel supported: \u0026ldquo;\u003cem\u003eWe've had a good relationship with the prescriber all along, and she gives us all the options and makes sure that we are very well aware of the possibilities of what may happen or may not happen, and she talks about everything very well\u003c/em\u003e\u0026rdquo; (Caregiver 3).\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe collaborative team-based approach, inclusive of the youth, was valued.\u003c/b\u003e Caregivers valued the team-based SDM process. \u003cem\u003e\u0026ldquo;I felt that the process itself, working together as a team, felt like he [youth] knows that he has support of all these people\u0026rdquo; (\u003c/em\u003eCaregiver 4\u003cem\u003e).\u003c/em\u003e Nearly all caregivers valued the youth\u0026rsquo;s preferences and appreciated that the intervention reinforced youth autonomy: \u0026ldquo;\u003cem\u003eAt the end of the day, she's the one that has to take the meds. It's her body. I want her to make her own decisions for her own body\u0026hellip;\u003c/em\u003e\u0026rdquo; (Caregiver 1).\u003c/p\u003e \u003cp\u003e \u003cb\u003eCaregivers reported increased knowledge and empowerment.\u003c/b\u003e The intervention increased caregivers' understanding of medications and encouraged more active involvement, leading to informed and empowered decisions. Caregivers especially liked the Option Grid decision aid in helping them make decisions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI found it [Option Grid] useful because then I knew what kind of medications he would be taking\u0026hellip;Then I could see if there was any side effects, what other medications he would be going on, or the classifications to just know in general. So I had a better understanding of how they're going to help them or work together.\u003c/em\u003e (Caregiver 7)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIf the caregivers used the app, they appreciated the weekly symptom tracking feature, which reminded them to pay attention to their youth\u0026rsquo;s functioning and side effects.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCaregivers reported positive outcomes.\u003c/b\u003e Those who chose to deprescribe typically saw reductions in negative medication reactions and behaviors:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eSo the one big thing that we noticed, believe or not, we noticed a huge change in less aggression. We also noticed, according to his endocrinologist, less gynecomastia, his gynecomastia stopped growing. So that was huge for Michael. We also noticed for him, he stopped putting on weight. He actually started losing weight.\u003c/em\u003e (Caregiver 6)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThose who did not deprescribe still felt successful; caregivers felt more empowered and equipped to have these discussions about deprescribing in the future.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCaregivers were positive about the research processes\u003c/b\u003e. Caregivers were overwhelmingly positive about the research process. They appreciated the clear consent process, brief surveys, and the respectful, accommodating research staff.\u003c/p\u003e \u003cp\u003e \u003cb\u003e[insert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e \u003cb\u003ehere]\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eClinicians\u003c/h2\u003e \u003cp\u003e \u003cb\u003eClinicians\u0026rsquo; (and their clinics\u0026rsquo;) views aligned with SDM and treatment optimization.\u003c/b\u003e Clinicians found it easy to integrate the intervention because it aligned with their own and their clinic\u0026rsquo;s philosophies related to SDM and a \u0026ldquo;less is more\u0026rdquo; approach. As stated by one clinician: \u003cem\u003e\u0026ldquo;I've always considered myself a collaborator\u0026hellip;I'm a collaborator with the parent, with the family, with the teacher, with the kid, with the patient. Like a journey. Walking together\u003c/em\u003e\u0026rdquo; (Clinician 2). Clinicians also highlighted shared values across their agency: \u0026ldquo;\u0026hellip;\u003cem\u003eWe try to do it [deprescribe] all the time. That's our goal is to try to have them on the least amount of medication or no medication\u003c/em\u003e\u0026rdquo; (Clinician 3). Similarly:\u003c/p\u003e \u003cp\u003e \u003cem\u003eI think the other practitioners we have at this site, it's just kind of something that we all naturally do. It doesn't feel good for families, and it doesn't feel good for the providers to have polypharmacy or using medications that are off-label. It just doesn't feel good.\u003c/em\u003e (Clinician 1)\u003c/p\u003e \u003cp\u003e \u003cb\u003eClinicians appreciated the structured framework and intervention tools.\u003c/b\u003e Clinicians valued how the intervention structured collaboration and deprescribing. As one stated:\u003c/p\u003e \u003cp\u003e\u003cem\u003e I like that it [the intervention] ensures that caregivers, particularly, maybe some teenagers, are aware that that [deprescribing] is a priority, that that is encouraged, and it's on paper. It [the intervention] sort of puts it to the forefront.\u003c/em\u003e (Clinician 3)\u003c/p\u003e \u003cp\u003eSimilar to caregivers, clinicians valued the triadic SDM process between youth, caregivers, and clinicians, noting how the intervention enhanced this triadic process. Clinicians, like caregivers, also appreciated the Option Grid tool, in particular.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI liked the Option Grid because I think it's nice to have had all the information in one place to be able to hand it to them and let them take with them. I think it's a lot of stuff that we go over with people\u0026hellip;But to have it on paper and to really be able to see it.\u003c/em\u003e (Clinician 1)\u003c/p\u003e \u003cp\u003eThere were mixed thoughts about whether they would use the other study tools (e.g. web-based portal that accompanied caregiver mobile phone app) in the future.\u003c/p\u003e \u003cp\u003e \u003cb\u003eClinicians provided considerations for implementation.\u003c/b\u003e Clinicians emphasized the importance of timing when deprescribing based on the youth\u0026rsquo;s stability in symptoms and life events. Some reported maintaining doses between reduction increments longer than the protocol\u0026rsquo;s recommended schedule: \u003cem\u003eI think sometimes there's fear around changing that or rocking the boat. And so going slower, I think a lot of them did. I still have a couple that, after the 18 weeks, were still in process because some sort of went down on a medication and then wanted to wait a little while and then consider the next one.\u003c/em\u003e (Clinician 1)\u003c/p\u003e \u003cp\u003eClinicians discussed the importance of acknowledging the success of dose reductions, not just removals. Clinicians also prioritized caregiver engagement and comfort with the treatment decision. It was important for caregivers to not have to commit to deprescribing to be part of the study. Similar to caregivers, clinicians agreed that although caregivers had mixed initial reactions, caregivers frequently felt relieved from their discomfort with the medications in the first place. Still, in some cases, caregiver fears about their youth\u0026rsquo;s decompensation led to maintaining the youth\u0026rsquo;s medication regimen. Finally, some clinicians suggested that the intervention be supplemented by additional education or non-pharmacological interventions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eClinicians recommended expanding the concept and practice of deprescribing.\u003c/b\u003e Clinicians perceived deprescribing as an ethical imperative: \u0026ldquo;\u003cem\u003eIt's a moral and ethical issue to not be continuing people on medications without good, documented reasons\u003c/em\u003e\u0026rdquo; (Clinician 2). They described a need for these concepts and practices to permeate the field, including incorporation into medical training and continuing medical education:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSo I think we need a cultural change. We're always pushing to prescribe, \u0026hellip; But you don't really hear, \"Okay. Once your person is better, when do you think about starting to take them off that medication?\" And so when you bring that up, kind of are on your own. (Clinician 2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eClinicians felt prepared and supported by the research team.\u003c/b\u003e The prescribers felt well prepared and supported through training resources and monthly consultations with the research team\u0026rsquo;s child and adolescent psychiatrist. Clinicians found the research process to add very little to their workload. In addition, their internal clinic administrative support further reinforced the adoption of the intervention.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eDiffering perspectives between caregivers and clinicians\u003c/h2\u003e \u003cp\u003eClinicians reported that the structured deprescribing guidance may need to consider slower tapering. Clinicians also recommended adding extra supports or non-pharmacological interventions when deprescribing. However, caregivers did not mention these needs. In addition, whereas clinicians were mostly motivated to deprescribe based on the youth\u0026rsquo;s stability in symptoms, caregivers were mostly motivated by the potential to reduce negative medication reactions.\u003c/p\u003e \u003cp\u003e \u003cb\u003e[insert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e \u003cb\u003ehere]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinician Themes and illustrative Quotes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSupporting Quotes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinicians\u0026rsquo; and clinics\u0026rsquo; views aligned with SDM and treatment optimization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;I usually always talk to the patients and family right off the bat. That, \"Just because we're starting this medication now doesn't mean it's something that's going to be forever, and that our ultimate goal would be to try to see if we can get you off the medication,\" and encouraging them to participate in their therapy\u0026hellip;And then once their symptoms are stable, the goal is to try to bring down those medications.\u0026rdquo; Clinician 4\u003c/p\u003e \u003cp\u003e\u0026ldquo;I try to have patients more so be aware that we ramp up and we also ramp down ahead of time\u0026hellip;that this is not just something we're going to slap them on, as we say, and leave it alone. It's an actively managed process even when we find the right doses and such because things change over time\u0026hellip;.\u0026rdquo; Clinician 3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinicians appreciated the structured framework and intervention tools\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI think sometimes it's just hard to keep track of a lot of the stuff that you hear in appointments like that - and just making sure everything gets talked about and the questions that they have get answered. So I think it helped structure that a little bit in a nice way.\u0026rdquo; \u003cem\u003e-\u003c/em\u003e Clinician 1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinicians provided considerations for implementation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;I think a lot of times, caregivers of kids on medicine, they're just waiting to get the kid off\u0026hellip;caregivers of kids are usually reluctant, and they're sort of last resort to prescribe. And so then when you're talking about deprescribing, it was very well received.\u0026rdquo; Clinician 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinicians recommended expanding the concept and practice of deprescribing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;So I'd like to see it [deprescribing] expanded into training, into nursing, into social working, so when everyone's sitting down, just like we look out for child abuse, we look out for these things.\u0026rdquo; Clinician 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinicians felt prepared and supported by the research team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;I don't think there was anything burdensome about it. There were a couple of things that were just a little different in terms of the way that we were documenting but still all stuff that we would have done in the course of an appointment, like the medication reaction checklist.\u0026rdquo; Clinician 1\u003c/p\u003e \u003cp\u003e\u0026ldquo;Folks seem very passionate. And I just thought it was helpful to really be presented with well-thought-out, well-researched points of view that made sense about deprescribing.\u0026rdquo; Clinician 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe demonstrated the feasibility of our study procedures and intervention. Caregivers and clinicians were positive about the intervention and study processes. About half of the triads chose to try deprescribing; no study-related serious adverse events occurred. The intervention seemed to reduce the number of medications and medication reactions, although the small sample and low baseline rates of medication reactions preclude firm conclusions. Qualitative themes suggested that the \u0026ldquo;less is more\u0026rdquo; approach aligned with the beliefs of our participating clinics and clinicians, and the intervention provided a structure to make SDM and deprescribing a reality.\u003c/p\u003e \u003cp\u003eThe strengths of our study include its mixed methods approach and real world context. To our knowledge, this is the first study of a structured, deprescribing protocol within child psychiatry. However, we have several limitations. This is a small feasibility study limited to two motivated, innovative clinics with values that align with deprescribing. The findings may not be generalizable to all settings. We were unable to distinguish between potential side effects, withdrawal symptoms, and relapse symptoms within our negative medication reactions checklist. Our medication review checklist was modified from the original version and not validated, and the brief caregiver-rated youth health check-ins within the phone application was not validated. We also had high rates of missing data on the caregiver-rated collaboRATE and youth health check-ins, which were collected via the app.\u003c/p\u003e \u003cp\u003eDeprescribing interventions include patient education, clinician audits, pharmacy reviews, and the use of structured protocols. In large reviews targeting the reduction of polypharmacy in various populations, deprescribing has led to efficacy for physical health outcomes in certain groups(Adams et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), but not all.(Keller et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) The use of structured tapering protocols and interventions used during the clinical encounter may be important in psychiatry.(Christensen et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Jerjes et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; M\u0026oslash;lgaard et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) To our knowledge, only one study has specifically investigated a structured deprescribing intervention in child psychiatry among youth seeking outpatient care. No patient-provider interaction or structured tapering protocol was used, and the authors reported no effects on medication (i.e., antipsychotic) use.(Penfold et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) More recently, deprescribing interventions with a very slow approach that use smaller and smaller incremental dose reductions over time are being promoted by the scientific and lived-experience communities.(Campbell et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Horowitz \u0026amp; Taylor, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Ramsdale et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn future studies, it will be important to improve measurement of relapse vs. withdrawal, follow participants longer, and test various deprescribing approaches and paces that may reduce withdrawal symptoms or relapse,(Stimpfl et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) including the hyperbolic approach to tapering medications.(Horowitz \u0026amp; Taylor, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Stimpfl et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) Finally, the intervention needs to be tested in other settings and in larger studies, ideally through randomized controlled trials, to test its effectiveness and safety.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eCaregivers, youth, and clinicians were highly motivated to deprescribe through a SDM process in outpatient settings. Our intervention demonstrated feasibility and, although conclusions are limited by our small sample, our intervention was associated with a reduction in the number of medications and negative medication reactions. We plan to test our intervention in a larger and more rigorous trial. Meanwhile, child psychiatry leaders and researchers can incorporate our findings into their clinical practice, advocacy, and policy efforts.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e The study was approved by the BRANY Institutional Review Board (Protocol #32704, Master File #23-10-216). Clinicians, caregivers, and youth provided informed consent / assent prior to the initiation of study activities.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003cp\u003eGlyn Elwyn\u0026rsquo;s academic interests are focused on shared decision making and coproduction. He is the editor of the 4th edition of the Textbook of Shared Decision Making (Oxford University Press, 2025). He is the Founder and Director of \u0026amp;think LLC, which owns the registered trademark for Option Grid.TM He owns copyright in measures of shared decision making and care integration, namely collaboRATE, integRATE, Observer OPTION-5, and Observer OPTION-12. These measures are freely available. Ben Fehnert and James King are co-founders of Fora Health, the company responsible for developing and providing the app utilized in this study. All other authors report no disclosures.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research was funded by The Charles H. Hood Foundation, Inc.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eERB- Funding acquisition, conceptualization, data curation, formal analysis, supervision, writing (original draft), methodology. JLM- Funding acquisition, conceptualization, data curation, formal analysis, supervision, writing original draft, methodology. GE- Funding acquisition, conceptualization, supervision, writing (original draft), methodology. SCA- Funding acquisition, conceptualization, data curation, formal analysis, writing (original draft), project administration, methodology. HBL-, data curation, formal analysis, writing (original draft), project administration, methodology. SB- implementation, writing (review and editing), methodology . AG- implementation, writing (review and editing), methodology. RB- data curation, formal analysis (qualitative), writing (review and editing). JK- Technology development, writing (review and editing), methodology. BF- Technology development, writing (review and editing), methodology.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe wish to extend our gratitude to the participants in this study for sharing their experiences and joining us in this endeavor. We are also thankful for the clinicians, staff and clinic administrators who worked so hard to make the study possible. We are grateful for the expertise and dedication of our colleague and co-designer of the deprescribing protocol, Milangel Concepcion Zayas. Finally, we would like to acknowledge the generous contributions of our parent advocates, Cheryl Guerin and Barb Drotos. They have been with us since the beginning in conceptualizing this work and moving it forward through the years, and their insights and perspectives were invaluable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAACAP. (n.d.). \u003cem\u003ePractice Parameters\u003c/em\u003e. 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Second generation antipsychotics (SGAs) for non-psychotic disorders in children and adolescents: a review of the randomized controlled studies. \u003cem\u003eEuropean Neuropsychopharmacology: The Journal of the European College of Neuropsychopharmacology\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(8), 600\u0026ndash;620. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.euroneuro.2011.04.001\u003c/span\u003e\u003cspan address=\"10.1016/j.euroneuro.2011.04.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":" psychiatric medications, children, adolescents, shared decision making, patient decision aids, deprescribing","lastPublishedDoi":"10.21203/rs.3.rs-9201326/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9201326/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground and objective: Rates of psychiatric medication use among U.S. youth have increased substantially and stakeholders are increasingly concerned. We tested the feasibility of a novel intervention that combines shared decision making and a structured deprescribing protocol during routine outpatient care with youth.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethods: Five clinicians delivered the intervention to youth 6 to 17 years old receiving three or more psychiatric medications or an off-label antipsychotic. Families completed assessments at baseline, 18- and 30-weeks. We collected data via surveys, medical records, and qualitative interviews.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults: We enrolled 31 youth, 29 received the intervention, and 13 of the 29 (45%) chose to deprescribe. Eleven of those 13 reduced their dose or stopped completely; 2 returned to their original dose. Of the 13, the mean dose-weighted medication use reduced from 3.9 (SD=1.38) to 2.9 (SD=1.41), and the mean number of medication reactions reduced from 1.3 (SD=2.21) to 0.3 (SD=0.48). In the 16 participants who chose not to deprescribe, the mean dose-weighted medication use and medication reactions reduced from 3.4 (SD=0.89) to 3.2 (SD=1.32) and 0.6 (SD=0.89) to 0.0 (SD=0.0), respectively. Youth functioning remained similar across groups. There were no study-related serious adverse events. Clinicians and caregivers considered the intervention feasible, valuable, and effective.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConclusions: Our intervention and procedures were feasible in real-world community settings. The intervention shows promising findings related to safety and effectiveness.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTrial registration: Our study was retrospectively registered with ClinicalTrials.gov. NCT # pending.\u0026nbsp;\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Deprescribing psychiatric medications in youth: A feasibility study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-31 17:33:21","doi":"10.21203/rs.3.rs-9201326/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"03cdcc38-e20d-41f1-8f06-0c00919ff2a0","owner":[],"postedDate":"March 31st, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-13T11:21:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-13T01:35:43+00:00","index":25,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-03T23:53:58+00:00","index":24,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T11:26:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-31 17:33:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9201326","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9201326","identity":"rs-9201326","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}