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. 2023 Aug 21;177(10):1107–1110. doi: 10.1001/jamapediatrics.2023.3068

Psychotropic Medication and Psychotropic Polypharmacy Among Children and Adolescents in the US Child Welfare System

Laura F Radel 1, Mir M Ali 1,, Kristina West 1, Sarah A Lieff 2
PMCID: PMC10442784  PMID: 37603358

Abstract

This cross-sectional study evaluates rates of psychotropic medication and polypharmacy use among youths in the US child welfare system compared with other youths with Medicaid coverage in 2019.


Nearly all children in foster care have experienced maltreatment or neglect and trauma from being separated from their families of origin, all of which can be developmentally disruptive.1 Literature identified children in the child welfare system as more likely than other children with Medicaid to receive psychotropic medication without accompanying psychotherapy or behavioral intervention.2,3

High rates of psychotropic prescription are concerning because of the limited safety and efficacy data for individuals younger than 18 years.4 However, few studies have examined psychotropic medication use among children in the US child welfare system nationally. Studies were limited to certain states or focused on a select class of psychotropic medication.2,3,4 Using a national Medicaid database, this cross-sectional study estimated the rate of psychotropic medication and psychotropic polypharmacy use among children and adolescents (hereafter, youths) in the child welfare system compared with other youths with Medicaid coverage.

Methods

This study followed the relevant portions of the STROBE reporting guideline and was conducted from July 7 to September 29, 2022. Per 45 CFR §46, institutional review board approval was not sought because the study did not involve human participant research. Data were drawn from the 2019 Centers for Medicare & Medicaid Services’ Transformed Medicaid Statistical Information System Analytic Files (TAF). The study sample included all Medicaid Children’s Health Insurance Program (CHIP) beneficiaries aged 3 to 17 years from all 50 states; Washington, DC; Puerto Rico; and the US Virgin Islands who were enrolled for at least 6 consecutive months in the year. The child welfare population was identified using the eligibility group code from the Demographic and Eligibility file, which identifies youths with Title IV-E adoption assistance, foster care, or guardianship care. We estimated rates of psychotropic medication and psychotropic polypharmacy (≥2 psychotropic classes) use and type of mental health condition by age group (3-17, 3-5, 6-11, and 12-17 years). Stata, version i7 was used for analysis.

Results

The sample included 719 908 beneficiaries in child welfare and 31 473 608 enrolled under other Medicaid eligibility codes. Of youths in the child welfare group, 26.25% had been prescribed a psychotropic medication and 13.27% experienced psychotropic polypharmacy compared with 9.06% and 3.11%, respectively, of other Medicaid-enrolled youths (Figure). The child welfare group had higher use rates than other Medicaid-enrolled youths for all ages, especially 12 to 17 years (34.30% vs 12.81% for psychotropic medication and 19.10% vs 5.05% for psychotropic polypharmacy).

Figure. Rate of Use of Psychotropic Medication and Psychotropic Polypharmacy Among Children and Adolescents Covered by Medicaid in 2019.

Figure.

The most common class of psychotropic medication in the child welfare group was stimulants (15.95%), followed by antidepressants (9.88%) and antipsychotics (7.87%) (Table). In the child welfare group, 42.85% had a diagnosed mental health condition, with trauma or stressor-related disorder (22.93%), attention-deficit/hyperactivity disorder (21.49%), and behavior or conduct disorder (11.67%) being the most prevalent diagnoses.

Table. Class of Psychotropic Medication and Type of Mental Health Condition Among Children and Adolescents Covered by Medicaid in 2019.

Medication class or condition Children and adolescents by age group, %
3-17 y 3-5 y 6-11 y 12-17 y
Child welfare (n = 719 908) Other Medicaid (n = 31 473 608) Child welfare (n = 124 351) Other Medicaid (n = 6 650 494) Child welfare (n = 283 343) Other Medicaid (n = 12 907 417) Child welfare (n = 312 214) Other Medicaid (n = 11 915 697)
Class of psychotropic medication
Antidepressants 9.88 2.75 0.55 0.08 6.28 1.41 16.86 5.68
Antipsychotics 7.87 1.74 1.06 0.45 6.40 1.40 11.91 2.83
Anticonvulsants 3.79 0.98 0.65 0.22 2.52 0.70 6.20 1.71
Antimanic 0.55 0.07 0.01 0.01 0.20 0.03 1.08 0.15
Antiparkinsonian 0.30 0.04 0.02 <0.01 0.15 0.02 0.56 0.09
Anxiolytics or sedatives 3.26 1.50 1.59 1.27 2.32 1.21 4.78 1.95
Benzodiazepines or barbiturates 1.30 0.79 1.08 0.68 1.06 0.62 1.61 1.04
CNS 1.08 0.25 0.05 0.01 1.16 0.29 1.42 0.34
Hypnotics 5.82 1.40 1.96 0.38 6.76 1.63 6.51 1.72
Stimulants 15.95 4.41 2.23 0.41 19.09 5.49 18.55 5.47
Type of mental health conditiona
Any 42.85 13.53 22.15 3.11 44.91 13.78 49.22 19.09
ADHD 21.49 6.46 4.40 0.92 24.75 7.87 25.35 8.02
Anxiety 8.71 3.26 3.01 0.49 7.35 2.50 12.21 5.64
Behavior or conduct disorders 11.67 2.59 4.45 0.80 11.43 2.87 14.77 3.30
Depression 7.55 2.54 0.26 0.03 2.93 0.83 14.64 5.78
Mood disorders 7.05 1.26 0.81 0.09 5.37 0.98 11.06 2.20
Other 0.22 0.09 0.03 0.01 0.08 0.03 0.41 0.20
Psychotic disorder 0.76 0.14 0.01 <0.01 0.38 0.06 1.40 0.29
Tourette syndrome or tic disorder 0.19 0.10 0.03 0.02 0.22 0.12 0.23 0.12
Trauma or stressor-related disorder 22.93 4.66 15.83 1.46 25.20 4.87 23.69 6.23

Abbreviations: ADHD, attention-deficit/hyperactivity disorder; CNS, central nervous system.

a

To identify beneficiaries with mental health conditions, we used Centers for Medicare & Medicaid Services’ standardized approach available from the Chronic Conditions Data Warehouse. This analysis relied on the annual Demographics and Eligibility file and the 4 claims files: inpatient, long-term care, other services, and pharmacy.

Discussion

This study found that 26.25% of youths in the child welfare system had a psychotropic medication prescription compared with 9.06% of other youths with Medicaid. The rate of psychotropic polypharmacy was also higher in the child welfare population. Given safety concerns and uncertainties about these medications’ long-term effects on brain development and metabolic adverse effects,5 judicious prescribing of psychotropic medications for child welfare–involved children remains a policy challenge. Guidance on safe prescribing and oversight of psychotropic medication use in the child welfare system has been issued at the federal level; however, implementation at the state level varies and may benefit from further policy initiatives.5,6

Study limitations include difficulty in identifying the child welfare population using administrative data. The TAF reports a single eligibility group code for each beneficiary. If a beneficiary is eligible for Medicaid’s CHIP through multiple eligibility pathways, the state assigns them the eligibility group affording that beneficiary the highest level of medical coverage. For example, children with disability in foster care may qualify for Medicaid’s CHIP through supplemental security income (SSI) eligibility and thus would appear as SSI beneficiaries rather than child welfare beneficiaries, causing an attenuation bias.

Supplement.

Data Sharing Statement

References

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement.

Data Sharing Statement


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