Reducing Psychotropic Medication Use in Foster-Care Children with a Personalized Medication Review.

The use of psychotropic medications in United States foster care children is an issue of growing concern among clinicians, child serving agencies, and legislators. Although pharmacologic interventions are accepted as part of multi-modal treatment strategies for many symptoms of mental illness, the relatively high use of psychotropic agents in this population, as well as the limited data on efficacy and both short and long-term adverse effect risks, have led to increased scrutiny. In addition to safety, issues of concern include indications for use, overdiagnosis, appropriate consent for treatment, oversight/monitoring of psychotropic prescribing and psychiatric consultation, and the availability of medication information for clinicians, foster parents, and care givers.

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessMore Youth Using Antipsychotics Concurrent With Other MedicationsMark MoranMark MoranSearch for more papers by this authorPublished Online:25 Jul 2014https://doi.org/10.1176/appi.pn.2014.8a7AbstractUse of second-generation antipsychotics along with other medications is growing most rapidly among youth who are less impaired, but one expert cites the likely effect of the FDA warning about suicidality with antidepressant use by youth.Use of second-generation antipsychotics (SGAs) concurrent with other psychotropic medications in children in the Medicaid program has increased in recent years, according to a report published online in the Journal of American Academy of Child and Adolescent Psychiatry.In the four-year period beginning in 2004, use of SGAs increased markedly and were frequently used along with one of four other classes of drugs, were used for long periods, and were increasingly prescribed in less-impaired children, the researchers found.“The present study illustrates that the trend of increasing SGA use, which is occurring in the context of stable or declining use of other medication, is due in large part to sustained concurrent use of SGAs with other medications, an exposure that is known to have serious side effects and unknown long-term effects and drug-drug interactions,” the researchers stated. “Even more problematic is that the exposure to concurrent SGA is increasing disproportionately among youth with less perceived comorbidity and impairment. Such trends indicate a growth in off-label prescribing among children for whom evidence of benefit is lacking.”In the study, researchers at Children’s Hospital of Philadelphia led by David Rubin, M.D., co-director of the Policy Lab at the hospital, used data from the Medicaid program to estimate the probability and duration of concurrent SGA use with different psychotropic medication classes over time and to examine concurrent SGAs in relation to clinical and demographic characteristics. Their analysis describes the epidemiology of concurrent SGA use with four psychotropic classes (stimulants, antidepressants, mood stabilizers, and alpha agonists) among a national sample of Medicaid-enrolled children aged 6 to 18.A “pattern” was identified when one or more psychotropic medication class was used for at least 14 consecutive days. Initially, all mutually exclusive psychotropic treatment patterns were identified in each of the study years; for example, stimulant alone and stimulant with antidepressant constituted two separate patterns. This process resulted in the identification of 101 unique patterns. The 30 most common patterns were retained, encompassing all medication use for 99.7 percent of the children in the sample. A child was identified as a user of psychotropic medications if he or she had at least one psychotropic treatment pattern within a year.The data analysis showed that while SGA use overall increased by 22 percent during the four-year period, about 85 percent of such use occurred concurrently with use of other psychotropic medications. By 2008, the probability of concurrent SGA use ranged from 0.22 for stimulant users to 0.52 for mood-stabilizer users. The concurrent SGA use occurred for long durations (69 percent to 89 percent of annual medication days).Although the highest users of concurrent SGA and other medications were children in foster care and disability Medicaid programs or children with behavioral hospitalizations, the most significant increases over time occurred among children who were income-eligible for Medicaid, did not have comorbid attention-deficit/hyperactivity disorder (ADHD), were not hospitalized, and had no intellectual disability.“We knew that antipsychotic use was increasing among youth, but were surprised to learn just how often children with ADHD or depression receive an antipsychotic as part of their treatment, and when they do, it is for sustained periods of time,” said Rubin. “In all likelihood, the use of the antipsychotics illustrates the great challenge clinicians are having when responding to disruptive and challenging behaviors in youth that don’t neatly fit common diagnostic categories. In a society that often doesn’t offer other services to respond to these behaviors, we should not be surprised at how quickly the use of antipsychotics has grown.”Child and adolescent psychiatrist David Fassler, M.D., a clinical professor of psychiatry at the University of Vermont, said the findings of this study are consistent with previous reports and with general clinical experience: there has been a significant increase in the use of atypical antipsychotics in the treatment of children and adolescents. But an important variable not addressed in the current study, said Fassler, was the Food and Drug Administration’s black-box warning on antidepressants issued in 2004—the first year of analysis in the study—which is likely to have significantly affected prescribing patterns, especially among pediatricians. “Although the authors noted that the increase in the use of these medications occurred in the context of ‘stable or declining use of other medication,’ they neglected to discuss the impact” of the label warnings that cautioned about suicidality risks with antidepressant use in children and adolescents, Fassler told Psychiatric News. “This would have been a helpful addition to the paper. Previous studies have suggested that this regulatory decision was at least partly responsible for the subsequent change in practice patterns.”“The authors raise appropriate concerns about duration of treatment and the safety and efficacy of polypharmacy,” he added. “Ultimately, however, the issue isn’t simply how many kids are receiving which medication or combination of medications. The real question is whether or not children and adolescents with significant psychiatric disorders are getting the comprehensive evaluation and treatment services they need and deserve.” ■“Growth in the Concurrent Use of Antipsychotics With Other Psychotropic Medications in Medicaid-Enrolled Children” can be accessed here. ISSUES NewArchived

Foster youth have higher rates of psychotropic medication use and concurrent multiclass psychotropic polypharmacy compared with nonfoster youth. However, less is known about the extent of multiclass psychotropic polypharmacy after adjusting for patient factors associated with psychotropic medication use OBJECTIVES: To (a) compare psychotropic medication use and psychotherapy use by youth in foster care to those not in foster care in the Oklahoma Medicaid population across various sociodemographic and clinical factors, and (b) determine if patient-related characteristics are associated with high levels of concurrent multiclass psychotropic polypharmacy. This cross-sectional, retrospective analysis was conducted using paid prescription, outpatient, and inpatient Oklahoma Medicaid administrative claims from calendar year 2016. Foster youth and adolescents aged 20 years or younger were identified (n = 9,325) and compared with the general Oklahoma Medicaid population of the same age (n = 639,868). Descriptive statistics highlight baseline demographic and clinical differences between the 2 groups. Multivariable logistic regression was used to determine if covariates were associated with concurrent multiclass psychotropic polypharmacy. A subgroup analysis of foster youth taking at least 1 psychotropic medication was also performed to determine factors associated with the highest level of concurrent multiclass psychotropic polypharmacy. Foster care was associated with higher odds of concurrent multiclass psychotropic polypharmacy regardless of presence of psychotherapy. Among the subgroup of foster youth taking at least 1 psychotropic medication, attention deficit hyperactivity disorder medications were the most commonly prescribed medication class, followed by antidepressants and anxiolytics when use was not chronic. However, at the highest level of chronic multiclass psychotropic polypharmacy (4-5 chronic concurrent medications), antipsychotics rose to the top, and anxiolytics were the least likely to be prescribed. Overall, the foster care population had the highest proportion of individuals with concurrent multiclass psychotropic polypharmacy (9.2% vs. 1.9%, P < 0.0001). The highest level of chronic multiclass psychotropic polypharmacy was more likely to occur in males (OR = 1.66, 95% CI = 1.40-1.96) and patients living in group homes (OR = 4.13, 95% CI = 2.02-8.44) or foster homes (OR = 1.66, 95% CI = 1.25-2.19). Being overweight or obese was associated with an 83% higher odds of being at the highest level of concurrent multiclass psychotropic polypharmacy (95% CI = 1.27-2.64). Despite higher psychotherapy use, high rates of psychotropic medication use and concurrent multiclass psychotropic polypharmacy in foster youth remain a concern for policymakers. Patterns observed at different levels of concurrent multiclass psychotropic polypharmacy may be key to identifying youth who require additional monitoring. Future research exploring factors associated with higher levels of psychotropic concurrent multiclass psychotropic polypharmacy in foster youth can lead to actionable interventions and important policy changes. This project was funded through the CHIP Health Services Initiative. Keast, Tidmore, and Lambert report contractual employment for the Oklahoma Health Care Authority. Nesser is an employee of the Oklahoma Health Care Authority, and Shropshire is an employee of the Oklahoma Department of Human Services. Keast discloses unrelated research grant funding from AbbVie, Amgen, Otsuka, and Purdue Pharma. Tidmore discloses unrelated research grant funding from Amgen and Otsuka. The remaining authors have no relevant disclosures or conflicts of interest to declare. Posters based on this study were presented at AMCP Nexus 2017; October 16-19, 2017; Grapevine, TX, and at the AMCP Annual Meeting 2018; April 23-26, 2018; Boston, MA.

The prevalence of psychotropic medication use among children and adolescents in foster care has received increasing attention from policymakers and scholars and led to responses from government. Most research has focused on school-age foster children; less is known about psychotropic medication use among foster youth transitioning to adulthood from care. Using data from a longitudinal study of transition-age foster youth (n = 611), this study examines the prevalence of psychotropic medication use over time, evaluates youths’ perceptions of the benefits of medication, and assesses associations between medication use and behavioral health problems. The overall rate of psychotropic medication use dropped from age 17 to age 19. Among youth with at least one behavioral health problem, rates of psychotropic medication use also declined over time. Decreases in psychotropic medication use between age 17 and 19 were found among youth with the following disorders: mania, an alcohol use disorder, and a non-alcohol drug use disorder. Behavioral health status and youths’ living arrangements were associated with the likelihood of psychotropic medication use at age 17, whereas only behavioral health status was associated with the likelihood of psychotropic medication use at age 19. Most youth reported either a positive or neutral view of the relative benefits of using medications. Among youths who had used medications, those in relative foster homes were less likely than those in non-relative foster homes to report negative views of their medications. The findings have implications for child welfare and health care professionals and policymakers.

Practical opportunities for pharmacists to optimize psychotropic medication use among foster youth

152 R studies have documented a substantial increase in the use of psychotropic medications by children and adolescents. Use of antidepressants by youths tripled between 1988 and 1996 (1), and similar increases have been seen in their use of other psychotropic medications (3). However, no data are available on the proportion of total mental health costs accounted for by use of psychotropic medications by youth. This column presents 1998 cost estimates from more than 100,000 privately insured children in all census regions. Costs were calculated from claims data from 28 large employers. In 1998 mental health expenditures for children with private insurance totaled some $5.5 billion, excluding services provided by state and local agencies and not paid for by private insurance. Expenditures for psychotropic medications for children covered by private insurance were approximately $670 million, or 11.9 percent of total expenditures. As Figure 1 shows, the proportion varied across age groups for children. About 4.3 percent of children received psychotropic medications, compared with 4.7 percent of adults (data not shown). As Figure 2 shows, stimulants were the most common medication prescribed in all age groups among children. Antidepressants accounted for 50 percent of the total costs for psychotropic medications among those aged 12 to 17, compared with 10 percent among oneto five-year-olds and 28 percent among children aged six to 11. We found that both the rates of use of psychotropic medications and their costs were lower among children and adolescents than among adults, despite the increased use of these medications among youths. At the same time, psychotropic medications now represent an appreciable part of children’s total mental health costs. Most of the cost for these medications are for the use of antidepressants by adolescents and stimulants by younger children.

Interstate variation in trends of psychotropic medication use among Medicaid-enrolled children in foster care

Five-Year Trajectories of Long-Term Benzodiazepine Use by Adolescents: Patient, Provider, and Medication Factors

The use of psychotropic medications in children and adolescents is increasing worldwide. However, caregivers' perspectives regarding the use of these medications in young people remain underexplored. To explore caregivers' perspectives towards the use of psychotropic medications in the treatment of mental disorders in young people. A systematic search was conducted across five databases (MEDLINE (ALL), Embase, PsycINFO, CINAHL, and Scopus) using a search strategy encompassing the concepts 'psychotropic medications', 'mental health', 'attitudes', 'young people', and 'caregivers' to identify relevant records published up to 25 March 2024. Records were screened by title and abstract against predefined criteria, followed by full-text review. Data were synthesised and presented in tables. Quality assessment was conducted using the Mixed Methods Appraisal Tool. After screening 1,296 records, 17 studies were eligible for inclusion. Findings were categorised into caregiver attitudes (n = 12), experiences (n = 2), and preferences (n = 9) regarding the use of psychotropic medications in young people. Most caregivers reported negative attitudes, with scepticism, fears of adverse effects and addiction, and doubts regarding efficacy commonly mentioned, including in those whose children had experience with psychotropic medication. Some caregivers were open to the use of psychotropic medications in their children if it was deemed necessary, however, psychotherapy was overwhelmingly the preferred treatment modality. The methodological quality of included studies was mixed; while many met criteria for appropriate sampling and analysis, few used validated measures, and high risk of bias due to non-response and reporting limitations was common. This review emphasises the importance of acknowledging and addressing caregiver concerns and actively involving them in the decision-making process. The substantial heterogeneity in study designs, measures, and participant characteristics reinforces the need for future research to employ validated instruments alongside both qualitative and interventional approaches to capture caregiver perspectives and the contextual factors that shape them.

Previous research has reported higher prevalence rates of anxiety and depression among musicians, compared to the general workforce. We compared the use of psychotherapy and psychotropic medication with other major occupational groups, and expected to find higher use among musicians. Musicians from the Norwegian Musicians’ Union ( n = 1,607) answered an online questionnaire about demographic characteristics, mental health, use of healthcare services and use of psychotropic medication. They were compared to a sample of the Norwegian workforce ( n = 2,550) from the Norwegian survey of level of living. Based on chi-square and logistic regression analysis, adjusted for age, sex, education, and cohabitation status, we found that musicians reported higher use of psychotherapy and psychotropic medication. Use of psychotherapy was reported most frequently among vocalists, while rock musicians reported the most widespread use of psychotropic medication. Overall, musicians had three-fold higher odds of use of psychotherapy and 50% higher odds of use of psychotropic medication compared to the general workforce. This is consistent with previous findings indicating high rates of sleep-difficulties and psychological distress among musicians. The results underline the importance of investigating both the content and quality of services provided.

The specific objectives were to investigate changes in the prevalence of psychotropic medication use for each year increase in age from three to six years old among children in foster care and to examine time-varying odds of longer duration of use by each year of age. A retrospective analysis of data on mental health and pharmacy services was conducted for 1,491 children age six and younger who were in foster care in 2010 and had at least 365 days in foster care during 2009-2011. A total of 178 children received at least one psychotropic medication from 2009 through 2011. Psychotropic prevalence and average days of use were calculated for each therapeutic class. Longitudinal regression models assessed the time-varying relationship between year of age and duration of use, controlling for demographic and clinical covariates. Approximately 12% of children age six and younger in foster care for 365 days or more received at least one psychotropic medication over the three-year study period. Prevalence of ADHD medication and antipsychotic medication and duration increased with each year of age (p<.001). In adjusted longitudinal models, each year increase in age was associated with a nearly twofold higher likelihood of longer duration of antipsychotic and ADHD medication use. Young children who initiated antipsychotic and ADHD medications before the age of six continued to receive them for longer periods of time. There is a critical need for long-term studies to evaluate the effect of chronic exposure on children's health and well-being.

The objective of this study was to compare on a national cohort of children with autism spectrum disorder (ASD) the concurrent use of >or=3 psychotropic medications between children in foster care and children who have disabilities and receive Supplemental Security Income, and to describe variation among states in the use of these medications by children in foster care. Studied was the concurrent use of >or=3 classes of psychotropic medications, identified from the 2001 Medicaid claims of 43406 children who were aged 3 to 18 years and had >or=1 annual claim for ASD. Medicaid enrollment as a child in foster care versus a child with disabilities was compared. Multilevel logistic regression, clustered at the state level and controlling for demographics and comorbidities, yielded standardized (adjusted) estimates of concurrent use of >or=3 medications and estimated variation in medication use within states that exceeded 1 and 2 SDs from the average across states. Among children in foster care, 20.8% used >or=3 classes of medication concurrently, compared with 10.1% of children who were classified as having a disability. Differences grew in relationship to overall use of medications within a state; for every 5% increase in concurrent use of >or=3 medication classes by a state's population with disabilities, such use by children in a state's foster care population increased by 8.3%. Forty-three percent (22) of states were >1 SD from the adjusted mean for children who were using >or=3 medications concurrently, and 14% (7) of the states exceeded 2 SDs. Among children with ASD, children in foster care were more likely to use >or=3 medications concurrently than children with disabilities. State-level differences underscore policy or programmatic differences that might affect the receipt of medications in this population.

When a child with a mental illness is being prescribed psychotropic medication. who decides whether the child should take the medication -- the parent or the child? What if the child is sixteen years of age? What if the child is in foster care: Should the parent or social service agency decide? Prior to administering psychotropic medication, what specific information should be provided to the person authorized to consent on behalf of the child? Should children be permitted to refuse psychotropic medications? If so, at what age should a child he able to refuse such medication What procedures should be put in place to forcibly medicate a child with psychotropic medication? There are numerous reports indicating that children in foster care are overmedicated as compared to children not in foster care. What are the reasons for this occurrence? Are there abuses within the foster care system? Should the state mental health agency monitor psychotropic medications for children, require oversight or a second opinion, or monitor abuse? What authority should a state agency have to stop prescribing psychotropic medication to children? This article will explore the overmedication of children with mental illness, with a specific emphasis on foster care children. Part I will examine the use of psychotropic medication on children, from the viewpoint of psychiatrists, pediatricians, parents, and children. Part II will explore the reasons why foster children receive psychotropic medications at a higher rate than children under their parents' care. Part IIl will provide an explanation of the consent procedures for children, and a critical inquiry into the manner psychiatrists and psychiatric hospitals undertake to address a minor's refusal to take psychotropic medication. Additionally, Part I will analyze various states' responses to addressing both the overmedicating of children as well as consent and refusal issues that ultimate]y result from the medication of children. It will offer recommendations for a model consent form to be utilized by psychiatrists and in-patient psychiatric hospitals. It will present the rights of children to refuse psychotropic medication as recommended and the procedure for overriding such refusal. Finally, Part III will analyze a survey of psychiatrists and pediatricians on the use of psychotropic medications to understand the existing consent procedures governing a minor's refusal to take psychotropic medications. The survey's design allows for a better understanding of the reasons behind the overmedication of foster children. The analysis will highlight the best practices and offer recommendations that provide for a state reporting and monitoring system.

This study describes the level of psychotropic medication use and patterns of such treatment among school-aged children in foster care. Structured survey interviews were conducted in the foster homes of 302 randomly selected children, aged 6-12 years, who were living in foster care for 6 months or more and placed from three county service areas. Follow-up mental health assessments using the existing system of care format were completed on 255 children. Sixteen percent of these school-aged children in foster care were found to have taken psychotropic medication during their lifetime. The most common class of medication used in the past year was stimulants (62%). Children who were older, from Caucasian and biracial backgrounds, and who lived in a group home more likely to have taken psychotropic medication in the past year. Among those children who received a clinician diagnosis of a severe psychiatric disorder for which medication is an accepted component of care, boys were more likely to receive medication treatment than girls. Sociodemographic characteristics and placement history variables may be influential in the level of psychotropic medication use among this population. Further research to examine the appropriateness and level of benefit of medication treatment in this population is needed.

There have been no comprehensive studies on trends in psychotropic medication use in child and adolescent inpatient settings. The aim of this nationwide study was to report changes in the psychotropic medication given to child and adolescent psychiatric inpatients across Finland and the factors associated with those changes. We asked the psychiatrist responsible for each inpatient to complete a questionnaire that included questions about the pharmacological treatment and background information. The data were collected on all inpatients on one selected study day in 2000 and 2011. Changes in the use of regular psychotropic medication were studied by comparing the data on 504 patients in 2000 and 412 patients in 2011. The study showed that there had been a significant increase in the use of psychotropic medication from 2000 to 2011. According to the multivariate analysis, the increase in psychotropic medication was associated with the study year (in 2000 39%, in 2011 58%), but could not be explained by changes in diagnostic profiles, age distribution, suicidality, violence or the Children's Global Assessment Scale scores. The use of combined psychotropic medication increased from 9% in 2000 to 25% in 2011. The increase in the use of antipsychotics among child inpatients was particularly noteworthy, with an increase from 10% to 32%. There is a need for evidence-based studies to clarify recommendations for indications and treatment practices when using psychotropic medication in children and adolescents. Cross-cultural studies of the use of psychotropic medication are warranted.