PolicyLab

A few months after the federal Government Accountability Office (GAO) issued a report on the use of psychoactive drugs by children in foster care in five states, a national study from PolicyLab at The Children’s Hospital of Philadelphia describes prescription patterns over time in 48 states. The updated findings show the percentage of foster children taking antipsychotics--a class of psychoactive drugs associated with serious side effects for children-- continued to climb in the last decade. At the same time, a slight decline was seen in other psychoactive medication use, including the percentage of children receiving three or more classes of these medications at once (polypharmacy).

Psychoactive drugs prescribed at higher rates for foster children

As public scrutiny has increased about the use of psychoactive medication by children over the past decade, children in foster care continue to be prescribed these drugs at exceptionally high rates compared with the general population of U.S. children. According to the PolicyLab study, 1 in 10 school-aged children (aged 6-11) and 1 in 6 adolescents (aged 12-18) were taking antipsychotics by 2007.

The research team looked at the 686,000 foster-care children enrolled in Medicaid annually in 48 states from 2002-2007, and saw that both overall psychoactive use and polypharmacy-- the practice of prescribing multiple types of psychoactive drugs at once — increased from 2002 to 2004, and then began to decline from 2005 to 2007. Prescriptions for antipsychotics, on the other hand, increased each year from 2002 to 2007.

“While it is encouraging to see fewer kids being prescribed multiple classes of drugs, and — to some degree — a slowing rate of growth in the use of antipsychotics by 2007, these medications are still being prescribed much too frequently to children in the foster care system,” said David Rubin, MD, MSCE, one of the study’s authors and director of PolicyLab.

Previous studies have established that children in foster care experience trauma and behavioral problems at higher rates than other children, and therefore use mental health services-- including psychoactive medications — more frequently. Recent research demonstrating serious side effects of these medications in children has focused attention on their use and prompted policy evaluation at both the federal and state level, particularly among high-risk populations like children in foster care.

Findings suggest that children in foster care may not have access to non-medication-based support to cope with psychological trauma

“We’re not saying these medications should never be used for children, but the high rate at which they’re used by children in foster care indicates that other interventions and supports, such as trauma-based counseling, may not be in place for them. In other words, health care providers may not have other, non-medication, tools to offer families dealing with mental health concerns,” said Rubin. “Responding to high and growing levels of antipsychotic use will not simply require efforts to restrict their use, but calls for larger investments in mental health programs that help these children cope with trauma psychologically.”

Prescription rates for both antipsychotic use and polypharmacy varied widely from state to state. Over the six-year period, antipsychotic use increased in all but three states. Conversely, 18 states showed an increase in polypharmacy, while 19 states showed decline and 11 no change. In 2007, states reported prescriptions of antipsychotics anywhere from 2.8 percent to 21.7 percent of the foster care population, and from 0.5 percent to 13.6 percent for children receiving multiple classes of psychoactive drugs. The authors note, however, that it’s not possible to use this study to compare states against one another. 

“In Illustrating both the national and state-specific trends in the use of psychoactive medications over time, we hope to provide a resource to officials at both the federal and state levels to help identify progress and prioritize intervention areas,” noted Meredith Matone, MHS, a research scientist at PolicyLab who co-authored the study currently published online in the journal Children and Youth Services Review.

Study's findings lay groundwork for state-level action

Bryan Samuels, Commissioner of the Administration on Children, Youth and Families (ACYF), said “the study’s findings contribute to ongoing Federal efforts to improve the oversight and monitoring of psychoactive medications by providing a new snap shot in time on how these drugs were used in almost every state in the nation.” ACYF, part of the U.S. Department of Health and Human Services, works across federal agencies and with the States to use the latest data and research to design and deliver the best health care services for vulnerable children.

In August, ACYF will bring child welfare, mental health, and Medicaid leaders from all 50 States, DC, and Puerto Rico together to address the appropriate use of psychoactive medications in state foster care programs.

More information

For more information about the study and on PolicyLab’s body of child welfare work, see the related project.

About PolicyLab at The Children’s Hospital of Philadelphia

PolicyLab develops evidence-based solutions for the most challenging health-related issues affecting children. PolicyLab engages in research that is both responsive to community needs and relevant to policy priorities, partnering with practitioners, policymakers, and families throughout the research process. Through its work, PolicyLab identifies the programs, practices, and policies that support the best outcomes for children and their families, disseminating its findings beyond research and academic communities as part of its commitment to transform evidence to action. 

Contact: Dana Mortensen, Children's Hospital of Philadelphia, 267-426-6092 or mortensen@email.chop.edu