Trends in Antipsychotic Use Among Youth in Foster Care Raise Concerns

Antipsychotics are a powerful class of medications that increasingly have been prescribed to children to treat disruptive behaviors, particularly for those in foster care. The trend is a disturbing one that has the attention of Pennsylvania state officials.

Researchers from PolicyLab at The Children’s Hospital of Philadelphia performed an in-depth analysis of data from Pennsylvania’s Medicaid program spanning the years 2007 to 2010 and 2012, with a specific focus on foster children between the ages of 3 to 18, at the request of the Commonwealth of Pennsylvania Department of Human Services (DHS). The research focused on the use of psychotropic medications, polypharmacy, off-label psychotropic medication, and behavioral health services.

Psychotropic medications are a class of drugs that is used to treat or manage mental health symptoms or challenging behaviors. Antipsychotic medications, which are primarily used to manage psychosis in serious mental illnesses such as schizophrenia and bipolar disorder, fall under this category. Since they can have significant side effects, antipsychotics should be prescribed under careful consideration and subject to ongoing monitoring over time.

“While data supports the use of antipsychotic medication for aggressive behaviors associated with several behavioral health diagnoses, there is little efficacy data to support use for more routine behavior problems in the absence of aggression,” the investigators noted in their report, “Psychotropic Medication Use by Pennsylvania Children in Foster Care and Enrolled in Medicaid: An Analysis of Children Ages 3-18 Years.”

The PolicyLab investigators found that between 2002 and 2007, there were 354,000 Medicaid-enrolled children ages 3 to 18 using antipsychotics, which was an increase of 62 percent. Although psychotropic medication use, including antipsychotics, was lower in 2012 compared with the four prior years of observation, the authors noted that the rates are still high.

Here are some of report’s key findings:

• For youth ages 6 to 18 in 2012, the use of psychotropic medications was nearly three times higher among youth in foster care than youth in Medicaid overall (prescribed at 43 percent versus 16 percent).
• The use of antipsychotics was four times higher among youth in foster care (22 percent) than youth in Medicaid overall (5 percent).
• More than half of youth antipsychotic users in Medicaid had a diagnosis of attention deficit hyperactivity disorder. The majority of these youth did not have another diagnosis that clinically indicated the use of antipsychotics.

“We commend the Department for recognizing this critical issue, and for working with PolicyLab and stakeholders throughout the state to develop recommendations to respond to this problem,” stated Kathleen Noonan, one of the study’s authors and founding co-director at CHOP’s PolicyLab. “While we know that many children benefit from medication, we also need to invest in proven alternatives, since too many children continue to be prescribed medications for non-approved indications.”

In light of the concerns identified from PolicyLab’s research and analysis, the investigators made several recommendations in their report. One suggestion is for DHS to expand investments in and reimbursements of non-pharmacological behavioral health interventions. Another is DHS should incorporate more robust psychotropic medication oversight and develop comprehensive guidance on psychotropic medication prescribing for children and youth, especially those in foster care. For more information on DHS’ response to the recommendations, see the press release.

The report, two years in the making, was funded by Casey Family Programs.