Children in foster care still face quality challenges in antipsychotic medication use

Significant quality challenges persist in antipsychotic medication use for children in foster care and other Medicaid-insured children, according to a new Rutgers University-New Brunswick study published in Health Affairs. Overall prescribing rates for children in foster care and other Medicaid-insured children have leveled off since a period of rapid growth in the early and mid-2000s. However, guideline-recommended practices such as use of nonpharmacological mental health services as first-line treatment, and monitoring of blood sugar and cholesterol for metabolic side effects of the medication, are frequently not followed, the research found.

Children in foster care, whose treatment receives closer oversight than other Medicaid children, were more likely than others to receive these guideline-recommended practices, said lead author Stephen Crystal, board of governors professor and associate director for health services research at Rutgers' Institute for Health, Health Care Policy and Aging Research. However, among children treated with antipsychotics, more than one-third of foster children, and more than two-thirds of other Medicaid children, failed to receive psychosocial mental health interventions during the three months preceding and the month following the start of antipsychotic treatment, he observed.

"Only 28 percent of foster children, and 18 percent of other children, received metabolic monitoring for both blood glucose and serum cholesterol," Crystal said, adding that children in foster care continue to receive antipsychotic treatment at much higher rates than other Medicaid-insured children (8.92 percent versus 1.51 percent among 0-17-year-olds in 2010).

In their article, "Rapid Growth of Antipsychotic Prescriptions for Children Who Are Publicly Insured, But Concerns Remain," the authors found that antipsychotic medication use peaked in 2008 among Medicaid children and 2009 among privately insured children, but levels have not returned to the pre-2000 rates.

"The 'new normal' levels of prescribing represent a substantially higher rate than was seen prior to the sharp expansion of the early 2000s," Crystal said. "Given safety concerns and uncertainties about long-term effects on brain development, encouraging judicious prescribing of antipsychotic medications for children remains a policy challenge and a priority."

The study used national and state-level Medicaid data, in addition to data from private health insurance. Co-authors on the paper included Thomas Mackie, Miriam Fenton, Shahla Amin, Sheree Neese-Todd, Mark Olfson and Scott Bilder.

One of his team's key findings was the need to continue to address antipsychotic use among children in foster care, Crystal noted. "Levels of use of antipsychotics among children in foster care were almost six times higher than in nonfoster care children in 2010. The state serves in loco parentis ("in place of the parent") for these children. Therefore, we have additional responsibility to ensure they are receiving the most appropriate treatment," he said.

The study found that antipsychotics continue to be prescribed for mental disorders not indicated by the Food and Drug Administration, particularly among children in foster care. For example, in 2010, 34 percent of antipsychotic prescriptions among foster care children were for Attention Deficit Hyperactivity Disorder (ADHD), anxiety or depression, compared to 18 percent among children not in foster care. "Doctors should consider other first-line treatments for children with these diagnoses," Crystal said.

An encouraging finding from the study is that higher rates of psychosocial interventions and metabolic monitoring have been achieved for children in foster care than for other Medicaid-insured children. "While these findings do suggest more careful monitoring of children in foster care who are prescribed antipsychotic medication, challenges remain in increasing safety monitoring and access to psychosocial treatment," Crystal said.

The study identifies several promising developments that have the potential to be important tools in improving prescribing quality for antipsychotics and other psychotropic drugs for children. These include the development in specialized managed care plans for children in foster care and new national quality measures for safe and judicious prescription of antipsychotic medication.

"Progress in a number of states that have implemented programs for oversight and quality improvement in children's psychotropic medication use is encouraging," said Crystal. "However, persistently high rates of antipsychotic treatment, particularly among foster children, alongside gaps in metabolic monitoring, over-reliance on use of multiple concurrent antipsychotic medications and underuse of psychosocial interventions, underscore enduring behavioral health care challenges.

"State and federal health care policymakers have opportunities to promote meaningful improvements that bear directly on the symptoms, social function and quality of life of foster children with mental health problems, by seizing opportunities such as emerging managed care models and new treatment guidelines," he concluded.