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. Author manuscript; available in PMC: 2015 May 1.
Published in final edited form as: J Child Fam Stud. 2014 May 1;23(4):666–674. doi: 10.1007/s10826-013-9882-3

Use of Psychotropic Medications among Youth in Treatment Foster Care

Sharon L Brenner 1, Dannia G Southerland 2, Barbara J Burns 3, H Ryan Wagner 4, Elizabeth MZ Farmer 5
PMCID: PMC4041742  NIHMSID: NIHMS549291  PMID: 24904200

Abstract

We describe the use of psychotropic medications among youth in treatment foster care (TFC). Data from 240 youth were coded to examine rates of medication use, including polypharmacy and an indicator of “questionable polypharmacy.” Fifty-nine percent of youth in TFC had taken a psychotropic medication within the past two months. Of the youth taking psychotropics, 61% took two or more and 22% met criteria for questionable polypharmacy. The majority of youth taking psychotropics also received psychosocial mental health services and were more likely to receive such services than youth not taking medication. Use of psychotropic medication use was not significantly related to demographic factors, maltreatment history, or custody. However, youth with more severe symptoms were more likely to be on medications and to be on multiple medications. Youth with “questionable polypharmacy” were less likely than other youth on multiple medications to have a recent visit to a psychiatrist.

Keywords: mental health services, psychotropic medication, polypharmacy, treatment foster care, children

Introduction

There is currently a great deal of both promise and uncertainty around use, rates, and patterns of psychotropic medication for youth with mental health disorders (Bentley & Collins, 2013). Rates of psychotropic medication use by children and adolescents have risen steadily since the early 1990s (Olfson, Blanco, Liu, Moreno, & Laje, 2006; Safer, Zito, & dosReis, 2003; Zito, et al., 2003). In particular, prescriptions for stimulants, anti-convulsant mood stabilizers, antidepressants, and atypical antipsychotics have increased among those 18 and under (e.g., Rushton & Whitmire, 2001; Olfson, et al., 2006; Zito, et al., 2003). This is despite the absence of clear data supporting the safety and efficacy of many of these medications in children or adolescents particularly when prescribed “off-label” without Food and Drug Administration (FDA) approval for a particular diagnoses or age group (e.g., Brown & Sammons, 2002; Jensen, et al., 1999; Riddle, Kastelic, & Frosch, 2001). While a number of psychotropic medications have documented benefits across a range of mental disorders in children and adolescents (Finding, et al., 2010; Fontanella, Bridge, & Campo, 2009; Swanson, Arnold, & Kraemer, 2008; The TADS Team, 2007; Walkup, et al., 2008), these medications also have serious side effects and medical risks (e.g., Boyer & Shannon, 2005; Jerrell, 2009; Jerrell & McIntyre, 2008; Malone, 1999; Morrato, et al., 2010; Safer et al., 2003). In addition to the overall rate of increase in psychotropic medications among youth, there has been an increase in use of concomitant psychotropic medications – or polypharmacy (Olfson, Marcus, Weissman, & Jensen, 2002; Constantine, Boaz, & Tandon, 2010; Dean, McDermott, & Marshall, 2006; dosReis, et al., 2005).

These data and concerns have raised particular interest about rates of psychotropic medication among youth who are in out-of-home care. Several studies have suggested that youth in foster care and other residential settings have elevated rates of psychotropic medication use (Connor, et al., 1998; Leslie, et al., 2010; Ryan, et al., 2008; Zima, et al., 1999; Zito, et al., 2008) and have raised concerns about whether these rates are clinically warranted or therapeutically beneficial. For instance, Zito and colleagues (2008) found a 37.9% annual prevalence rate of psychotropic medication use for youth in foster care. Among those taking medications, 72% took two or more psychotropic medications, while 41.3% took three or more medications. Data on residential care have shown substantially higher rates of psychopharmacology, with an average of 75-79% of youth in these settings taking psychotropic medications and high rates of polypharmacy (Conner, et al., 1998; Huefner, et al., 2012; Ryan, et al., 2008).

Research on medication use in out-of-home care has, to date, rarely included Treatment Foster Care (TFC), a community-based intensive treatment-focused intervention for youth with emotional, behavior, and mental health problems (Farmer, et al., 2002). Youth in TFC often have severe and complex behavioral, emotional, and mental health needs. In response to these problems and issues, youth in TFC tend to receive a wide range of services (both within the TFC home and from the broader child-serving community) and show high rates of psychotropic medication use (Breland-Noble, et al., 2002). In a study examining psychotropic medication use among adolescent youth in TFC and group homes from 1999-2001, 67% of youth in TFC had taken a psychotropic medication within the past four months (Breland-Noble, et al., 2004). However, no studies have examined more recent psychotropic medication use or polypharmacy rates among TFC youth, and little is known about patterns of psychotropic medication use among youth in TFC settings.

Overall, the existing data, gaps in knowledge, and trends raise questions on a number of fronts. First, because of concerns over high rates of polypharmacy and off-label use of psychotropic medications across clinical and residential treatment settings, researchers and policymakers are working to establish indicators of questionable psychotropic polypharmacy (e.g., Essock, et al., 2009). Second, although adherence to best practice for many child and adolescent mental disorders suggests the potential benefits of combining medication with other psychosocial/behavior interventions, (Burns, Hoagwood, & Mrazek, 1999; Walkup, et al., 2008; TADS Team, 2007; Swanson, et al., 2008), there has been concern that some data may suggest increasing numbers of patients are receiving medications without concurrent mental health services (Olfson & Marcus, 2010). Third, there is concern that increasingly psychotropic medications are prescribed by general medical practitioners rather than psychiatrists (Mark, Levit, & Buck, 2009). Whether or not psychiatrists and general practitioners differ in prescribing practices is clear (Chen, et al., 2006; Olfson, 2010), so the long-term effect on polypharmacy and questionable polypharmacy rates is unknown. Fourth, there have been concerns raised about rates of psychotropic medication use in foster care and other out-of-home placements, but relatively sparse data to examine patterns, predictors, or outcomes of psychotropic medication use in these settings.

The purpose of the current article is to explore the prevalence of psychotropic medication use and polypharmacy among youth in treatment foster care. In an effort to paint a broad picture of this issue in TFC and explore key issues in the field, we examine individual-level factors related to medication use and provide a preliminary examination of “questionable polypharmacy.” To examine whether medication is being used in conjunction with or as a substitute for other types of interventions, we compare other services for emotional and behavioral problems among youth who are taking psychotropic medication versus those who are not, as well as among youth with monopharmacy versus polypharmacy.

Method

Data came from a randomized trial to test the effectiveness of an enhanced TFC model conducted in “usual care” agencies between 2003 and 2008 in a southeastern state (Farmer, Burns, Wagner, Murray, & Southerland, 2010a). Fourteen TFC agencies were recruited for the study, and randomization was done at the agency level (with half receiving the intervention training and consultation and half serving as control agencies providing care as usual).

Participants

Participants were 247 youth (ages 2 to 21 years) and their foster care parent. Of these 247 youth, baseline data on psychotropic medication use was missing for 7 youth, so this article reports on the 240 participants with available data. As described in Table 1, the sample was 45.4% female with a mean age of 13.0 years (SD = 3.8). The racial/ethnic composition included 77 white youth (32.1%), 138 African American youth (57.5%), and 25 youth (10%) from other racial/ethnic groups. Youth were primarily in state custody (83.3%), and 71.1% had a history of maltreatment. The majority of youth (73.8%) entered TFC from a prior out-of-home placement.

Table 1. Baseline Characteristics of Youth in Treatment Foster Care.

Total
(N=240)
Variable N %
Age (years; M±SD) 13.0±3.8
Race
 White 77 32
 African American 138 58
 Other 25 10
Female 109 45
State custody 200 83
History of maltreatment 172 71
Months in current TFC home (M±SD) 20.4±25.5
SDQ (M±SD) 16.1±6.8
Any psychotropic medication 142 59
 Antidepressants 54 22
 ADHD/Stimulant medication 95 38
 Antipsychotics 68 26
 Mood stabilizers 29 12
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All data in the current analyses come from interviews with treatment parents. In TFC, treatment parents are viewed as both primary caregivers and as front-line treatment providers. Hence, they receive more training, support, and supervision that “traditional” foster parents and are responsible for daily implementation of all aspects of the youth's treatment plan, including medication administration. For this study, treatment parents had a mean age of 48 (SD = 10), 74% were African American, and they had been serving as a treatment parent for the focal youth for an average of 20 months.

Data

Data come from in-person interviews conducted at baseline with treatment parents. All data reported in this article were collected as part of the baseline assessment before implementation of the intervention; therefore, randomization is not accounted for in the data reported. (See Farmer, Burns, et al., 2010a and Murray, Southerland, Farmer, & Ballentine, 2010 for a description of the intervention.) All study procedures were approved by the Duke University Institutional Review Board.

As part of the interview, treatment parents were asked if their TFC youth had taken any type of medicine for emotional or behavioral issues in the past two months. Since these individuals were responsible for daily administration of medications, as well as documentation of such use, they were quite knowledgeable about the youth's medications. All interviews were conducted in treatment foster homes. Therefore, if the treatment parent was not sure or if the interviewer was not clear about the medication responses, the treatment parent was asked to show the medication container to the interviewer, so that information could be recorded from the label. Treatment parents were asked to report all medications that the youth had taken in the past 2 months and to indicate whether he/she was still taking any reported medications.

To assess other service use, treatment parents completed a modified version of the Child and Adolescent Services Assessment (CASA) to determine the use of services for emotional and behavioral problems (Ascher, Farmer, Burns, & Angold, 1996; Farmer, Angold, Burns, & Costello, 1994). The CASA collects data on use of an extensive array of behavioral health services, including inpatient, outpatient, volunteer (informal), school based, and ancillary services. The version used in this study collected information on whether a service was used within the past two months. A dichotomous “yes” or “no” dummy-coded variable was created for each CASA service sector indicating whether or not the service had been used within the past two months. The CASA parent report version has good to excellent test-retest reliability (K = .62 to 1.0 for professional services) and very good correspondence with provider records (Ascher, et al., 1996; Bussing, Mason, Leon, & Sinha, 2003).

Treatment parents completed the 25-item Strengths and Difficulties Questionnaire (SDQ; Goodman, Ford, Simmons, Gatward, & Meltzer, 2000) to assess severity of psychopathology among sample youth. Responses to 20 of the 25 items generate a total difficulties score, based on subscale scores for emotional symptoms, conduct problems, hyperactivity, and peer problems (Bourdon, Goodman, Rae, Simpson, & Koretz, 2005). The total difficulties score has good internal consistency (α = .82; Goodman, 2001) and has been normed for general population samples.

Data analysis

Data reduction

Using guidelines reported in previous studies of medication use in children and adults (e.g., Essock, et al., 2009; Fontanella, et al., 2009; Ferguson, Glesener, & Raschick, 2006), psychotropic medications were coded into five possible categories: (1) antidepressants; (2) Attention-Deficit/Hyperactivity Disorder (ADHD)/stimulants; (3) antipsychotics; (4) non-antipsychotic mood stabilizers/antimanic agents; and (5) anxiolytics (antianxiety medication). (Appendix I in Essock et al., 2009 provides a list of most medications and classifications for further reference.) Psychotropic medication use was coded dichotomously as a single “yes” (1) or “no” (0) dummy-coded variable if youth took a medication from any of the categories above. No youth were taking anxiolytic medication and so medications were coded only into the other four categories. A second dummy-coded dichotomous variable was created for polypharmacy indicating “yes” or “no” for youth taking two or more psychotropic medications.

Indicators of questionable polypharmacy in the current sample were derived from the description by Essock and colleagues (2009) of the guidelines for children developed by psychopharmacology experts serving on a scientific advisory committee in New York. Based on these criteria, a third dichotomous “questionable polypharmacy” variable was created when an indicator of questionable polypharmacy was present, including two or more medications within the same class, and/or three or more psychotropic medications. These designations were established for children because of the potential for negative drug interactions and metabolic side effects (Essock et al., 2009). The designation of questionable polypharmacy was coded conservatively in this study so that it did not include two or more stimulants or a stimulant and antihypertensive since these combinations are often included in “usual care” to adequately address inattention throughout the day without insomnia at bedtime (e.g., Ferguson, 2006). In addition, data about whether the youth was “still taking the medication” was utilized to assure that all questionable pharmacology referred to concomitant medications, not sequences of medications across the 2-month reporting period. Thus, current coding of questionable pharmacology followed established guidelines and provides a conservative indicator of this phenomenon.

A dichotomous “yes” or “no” dummy-coded variable was created for each CASA service sector indicating whether or not the service had been used within the past two months. Because youth often receive services from multiple additional sources while in TFC, these service categories are not mutually exclusive. The focal categories of service type were: case management; outpatient mental health; school services; social services; and psychiatrist visits.

Analytic Methods

All analyses were run in StataSE 11 (StataCorp., 2009) and included logistic regression, chi-squares, and t-tests. Results reported here focus on bivariate relationships. More complex and multivariate approaches were also run (and confirm the results reported here), but the relatively small sample size made parameter estimates questionable and unstable. Therefore, reported results focus on bivariate analyses.

Results

Among the sample youth, 142 (59.1%) took a psychotropic medication within the two months preceding the interview. Of these youth, 86 (60.6%) took two or more medications. No use of anxiolytics was reported. Within the two months prior to the baseline interview, 21.9% of youth took an antidepressant, 38.5% took a stimulant or medication for ADHD, 27.5% took an antipsychotic, and 11.7% took a mood stabilizer (Table 1). All youth taking antipsychotic medications were taking second generation (atypical) antipsychotics.

Table 2 shows the distribution of youth taking psychotropic medication, multiple psychotropics, and questionable polypharmacy. Among youth on psychotropic medication, approximately 40% were on one medication, 36% were on two, and 25% were on three or more. Questionable polypharmacy was coded for 13% of the total sample and 36% of those who were on multiple medications.

Table 2. Percentage of youth taking one or more medications among full sample (N = 240) and among youth on medication (N = 142).
N = 240 N = 142
N = 240 n % %
One medication 56 23.3 39.4
Two medications 51 21.2 35.9
Three medications 22 9.2 15.5
Four or more medications 13 5.4 9.2
Questionable Polypharmacy 31 12.9 21.8
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Table 3 shows bivariate relationships between youth characteristics/history and medication use. Youth taking psychotropic medication had significantly higher SDQ scores (M = 17.2, SD = 6.2) compared to youth not taking medication (M = 14.1, SD = 7.4; t = -3.04, p < .01). SDQ was also significantly higher for youth on multiple medications than for those on a single psychotropic (t = -1.98, p < .05). There were no differences in SDQ for youth on “any polypharmacy” vs. “questionable polypharmacy.”

Table 3. Bivariate relationships between youth characteristics and medication use.

Means and Percents
Any medication
(versus none)		 Polypharmacy
(versus one medication)		 Questionable Polypharmacy
(versus polypharmacy)
None Any med One med Polypharm Polypharm Questionable
Age (years) 14.1 13.1 13.1 13.3 13.3 13.2
Months in TFC home 14.8** 25.1 20.5 28.2 24.7 34.3
SDQ Total Score 14.1** 17.2 15.8* 18.2 18.2 17.8
Sex (female) 51.0 41.5 46.3 39.5 43.6 32.2
State custody 88.4 81.7 83.3 80.2 80.0 80.6
Maltreatment 62.9 70.4 77.8 65.1 61.8 71.0
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*

p<.05;

**

p<.01;

***

p<.001

Race and sex were not significantly related to medication use. Most indicators of a youth's history also were not related to medication use (e.g., custody, maltreatment). However, time in the TFC home was related, with youth who were on psychotropic medications having an average length of stay of 25 months (at the time of the baseline interview) compared to 14 months for those who were not on psychotropic medication.

The continuous measure of age was not related to medication use. However, analyses with age as a categorical measure suggested some broad age-graded differences. There were very few pre-school aged children in the sample (n=14) and only one child aged 2-5 was taking psychotropic medication. Among youth ages 6-12, 77% took a psychotropic medication compared to 55% of youth ages 13-21. Logistic regression analyses with any psychotropic medication use entered as the dependent variable indicated that the odds of psychotropic medication use were significantly higher among youth 6-12 relative to those aged 13-21 (OR = 2.71, 95% CI: 1.25 – 5.10, p < .01); odds of ADHD medication use among 6-12 year olds were also significantly higher relative to those 13 and above (OR = 4.12, 95% CI: 2.29 – 7.43, p < .0001). No other medication categories were different across these age groups. The odds of polypharmacy (OR = 1.50 CI: 0.85 – 2.65, p = .16) or questionable polypharmacy (OR = 1.59, p = .24) also were not significantly different for those aged 6-12 years compared with those 13 and above. Because only one child aged 2-5 was taking a psychotropic medication, all subsequent analyses only include the 226 youth age 6 years and older.

We explored whether medications appeared to part of a multi-faceted approach to treatment or if medications appeared to be related to less use of other services. In general, youth who were taking psychotropic medication were also more likely to be receiving other types of services. Each service use sector was examined for youth ages 6 and above taking psychotropic medications, and compared to rates for youth who had not taken psychotropic medication within the past two months (see Table 4). A chi-square test of goodness-of-fit was performed to examine whether or not each service sector was distributed similarly for those taking psychotropic medications compared to those who were not. Tests indicated significant differences for case management (X2 (1) = 9.92, p < .01), social services/community support (X2 (1) = 3.97, p = .05), services within the school (X2 (1) = 12.04, p < .01), and outpatient treatment (X2 (1) = 5.09, p < .05), with a higher percentage of youth taking psychotropic medication receiving services.

Table 4. Other service use by medication subgroups.

Percent Using Service
Any medication
(versus none)		 Polypharmacy
(versus one medication)		 Questionable Polypharmacy
(versus other polypharmacy)
None Any med One med Polypharm Polypharm Questionable
Case Management 50.6** 70.9 63.6 75.6 79.6 71.0
Social Services 38.8* 51.8 52.7 52.3 49.1 54.8
School Services 36.5** 60.3 49.1* 67.4 76.4 58.0
Outpatient Treatment 47.0* 62.4 52.7* 68.6 72.7 64.5
Psychiatrist visit 6.1*** 51.4 44.4 55.8 63.6* 41.9
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*

p<.05;

**

p<.01;

***

p<.001

Chi-square analyses were also run to compare services for those taking only one psychotropic medication with those taking two or more medications. Although youth taking two or more psychotropic medications were more likely to be receiving most types of services, only school services (X2 (1) = 4.72, p < .05) and outpatient treatment (X2 (1) = 4.00, p < .05) were significantly higher.

For most types of services, youth with questionable polypharmacy did not significantly differ from others on polypharmacy. The only area where these two groups were significantly different was on visits to a psychiatrist, with youth on questionable polypharmacy less likely to have visited a psychiatrist in the past two months (X2(1) = 3.78, p< .05). Overall, 42% of youth with questionable polypharmacy had seen a psychiatrist in the past 2 months, compared to 64% of other youth on polypharmacy. Given this finding, visits to a general medical practitioner were also examined. Only seven youth taking psychotropic medication had seen such a general practitioner for emotional or behavioral problems within the last two months. No significant associations were found between visits to these physicians and any type of medication use.

Discussion

This paper provides a preliminary examination of medication use and associated factors among youth in treatment foster care (TFC). There have been concerns in recent years about rates and patterns of medication use among youth in out-of-home placements, but there has been very sparse knowledge about what occurs in TFC, a residential option that occupies a space on the residential continuum between traditional foster care and congregate care settings.

Psychotropic medication use was prevalent among the youth in this TFC sample, with 59% of youth reported to have taken one or more psychotropic medications within the past two months. This is consistent with the rate of use reported by Breland-Noble and colleagues (2004) for youth in TFC in the late 1990s. It also appears to reflect TFC's role in the continuum of residential settings, with rates of medication use that are higher than traditional foster care but lower than in more restrictive congregate care settings.

Regarding psychotropic polypharmacy, 60% of youth on psychotropic medication were taking two or more medications. This means that 36% of the overall sample was taking multiple psychotropic medications.

Rates of medication use varied by age, and the highest rate of use (77%) was among youth ages 6-12. This was almost entirely accounted for by higher rates of medications for ADHD. Although those 6-12 had higher rates of medication use, they did not have higher polypharmacy rates compared to youth who were 13-21. Recent reports suggest that toddlers and preschool-age children are receiving prescriptions for psychotropic medication at increasing rates (Olfson et al., 2010; Zito, et al., 2007); however, in the current sample, only one young child (age 5) was taking a psychotropic (an atypical antipsychotic), with no use reported among the very small sample of preschool-aged youth.

We conducted preliminary analysis of questionable polypharmacy rates. Among the youth taking psychotropics, 22% met criteria for the indicator of questionable polypharmacy. This is approximately 13% of the youth in TFC, and is comparable to the rate found by Essock and colleagues (2009) in their examination of questionable polypharmacy prescribing practices using New York State Medicaid claims.

In examining other services to address mental health/behavioral issues, youth taking psychotropic medication were more likely to be receiving other mental health services compared to youth who did not take medication. The range of service use among TFC youth taking psychotropic medication in this sample is encouraging, since optimal treatment often includes both pharmacological and psychosocial interventions. Overall, the use of services by youth in this TFC sample is consistent with previous studies showing high utilization of mental health services in school and outpatient settings by youth in TFC, group homes, and general foster care (Breland-Noble, et al., 2005; Farmer, et al., 2010b). These preliminary findings also suggest a gradation in services that mirrors complexity of medications, with youth who were on multiple medications showing, on average, higher service use than youth on a single medication.

The current study also examined recent visits to a psychiatrist (occurring within the past two months). Medication use, polypharmacy and all categories of psychotropic medication were associated with psychiatrist visits, with the percentage of youth on medication who had seen a psychiatrist recently ranging from 42-64%. Visits to non-psychiatrist medical doctors for emotional or behavioral problems were infrequent in this sample. Thus, youth in this TFC sample appear to be seeing psychiatrists at higher rates compared to a recent study of youth in outpatient settings, which found that the majority of youth received psychotropic medication from nonpsychiatrists (Comer, Olfson, & Mojtabai, 2010). These data suggest some concerns about the rates of psychiatric visits for youth on questionable psychopharmacologic combinations. Youth with questionable psychopharmacology patterns were less likely than other youth on multiple medications to have seen a psychiatrist in the past two months. Given usual intervals for psychiatrist visits, it is very likely that some youth had psychiatric visits that fell slightly outside of the reporting period. However, it is not clear why this would be more true for youth with questionable polypharmacy than for youth with other polypharmacy. Hence, this finding suggests that need for additional work on medication prescribing, oversight, and monitoring.

It is also interesting to note that, while not significant (perhaps because of the relatively small sample in these categories), nearly all service use (except for involvement with social services) is lower for the questionable polypharmacy group. This suggests the need for additional research to explore the overall mix of services for this subset of youth, not just their use of medications.

Study Limitations

The current study examines a relatively small sample of youth in TFC limited to one state, and the findings many not generalize to other youth in TFC across the country. Medication use was based on caregiver report, which is not as accurate as medical records or insurance claim data. In particular, examination of questionable polypharmacy was limited by the available data. In addition, more information is needed about psychiatric diagnoses and the quality, intensity, and duration of mental health services before it is clear whether or not the services are clinically adequate. Information about psychiatry visits across a longer time span would be helpful for understanding differences among youth receiving psychotropic medication from psychiatrists compared with other medical practitioners, and a longer observational period would provide more information about whether or not physician visits fall within recommended timeframes for pediatric psychotropic medications. The sample size (particularly of the polypharmacy subgroups) precluded multivariate analyses to more fully explore the reported relationships.

Future Directions

Overall, we found moderately high rates of psychotropic medication use among youth in TFC. These rates are higher than those found in outpatient clinical settings or traditional foster care but slightly lower than rates found in more restrictive residential settings. TFC youth, however, appear to receive clinically questionable combinations of psychotropic medications at rates similar to those of other Medicaid populations, but this needs corroborating in future studies. The current paper simply describes rates and patterns of medication use at a point in time. Additional work is needed to more fully model factors that appear to increase or decrease use of medication, polypharmacy, and questionable polypharmacy.

While practice parameters exist for pediatric psychotropic medication prescribing (Walkup & The AACAP Work Group on Quality issues, 2009; Crismon & Argo, 2009), these guidelines are not binding and state and other regulatory agencies are typically ill-equipped to keep up with rapidly changing trends in the psychiatric field (Leslie, et al., 2010). In addition, the American Academy of Child and Adolescent Psychiatry practice parameter was written for child psychiatrists, and may not be adequately disseminated to other providers. Further discussion is needed about balancing access to care versus the risks of psychotropic medications when they are prescribed in a way that does not meet best practice guidelines or are prescribed off-label outside of FDA approval (Mark, et al., 2009).

These findings also reiterate the point that key mechanisms of change need to be carefully assessed and modeled in studies of comprehensive mental health treatments. It is important to understand the role of psychotropic medications in observed outcomes for youth and to examine the potential combined and interactive effects of multiple intervention approaches/modalities on youth outcomes across treatment settings. Given the high rates of medication use by youth in many interventions, including TFC, it is critical to include such information in our understanding of outcomes, trajectories, and predictors as the field attempts to more fully understand active ingredients of treatment.

Contributor Information

Sharon L. Brenner, Email: sharon.brenner.phd@gmail.com, Services Effectiveness Research Program, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, DUMC Box 3454, Durham, NC 27710.

Dannia G. Southerland, Services Effectiveness Research Program, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, DUMC Box 3454, Durham, NC 27710

Barbara J. Burns, Services Effectiveness Research Program, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, DUMC Box 3454, Durham, NC 27710

H. Ryan Wagner, Services Effectiveness Research Program, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, DUMC Box 3454, Durham, NC 27710.

Elizabeth M.Z. Farmer, School of Social Work, Virginia Commonwealth University, Richmond, VA

References

  1. Ascher BH, Farmer EMZ, Burns BJ, Angold A. The Child and Adolescent Services Assessment (CASA): Description and psychometrics. Journal of Emotional and Behavioral Disorders. 1996;4:12–20. [Google Scholar]
  2. Bentley KJ, Collins KS. Psychopharmacological treatment for child and adolescent mental disorders. In: Franklin C, Harris MS, Mears PA, editors. The School Services Sourcebook. 2nd. NY: Oxford; 2013. [Google Scholar]
  3. Boyer EW, Shannon M. The serotonin syndrome. New England Journal of Medicine. 2005;352:1112–1120. doi: 10.1056/NEJMra041867. [DOI] [PubMed] [Google Scholar]
  4. Bourdon KH, Goodman R, Rae DS, Simpson G, Koretz DS. The Strengths and Difficulties Questionnaire: US normative data and psychometric properties. Journal of the American Academy of Child and Adolescent Psychiatry. 2005;44:557–564. doi: 10.1097/01.chi.0000159157.57075.c8. [DOI] [PubMed] [Google Scholar]
  5. Breland-Noble AM, Elbogen EB, Farmer EMZ, Dubs MS, Wagner HR, Burns BJ. Use of psychotropic medications by youths in therapeutic foster care and group homes. Psychiatric Services. 2004;55:706–708. doi: 10.1176/appi.ps.55.6.706. [DOI] [PubMed] [Google Scholar]
  6. Breland-Noble AM, Farmer EMZ, Dubs MS, Potter E, Burns BJ. Mental health and other service use by youth in therapeutic foster care and group homes. Journal of Child and Family Studies. 2005;14:167–180. [Google Scholar]
  7. Brown R, Sammons MT. Pediatric psychopharmacology: A review of new developments and recent research. Professional Psychology – Research & Practice. 2002;33:135–147. [Google Scholar]
  8. Burns BJ, Farmer EMZ, Angold A, Costello EJ, Behar L. A randomized trial of case management for youths with serious emotional disturbance. Journal of Clinical Child Psychology. 1996;25:476–486. [Google Scholar]
  9. Burns BJ, Hoagwood K, Mrazek PJ. Effective treatment for mental disorders in children and adolescents. Clinical Child and Family Psychology Review. 1999;2:199–253. doi: 10.1023/a:1021826216025. [DOI] [PubMed] [Google Scholar]
  10. Bussing R, Mason DM, Leon CE, Sinha K. Agreement between CASA parent reports and provider records of children's ADHD services. Journal of Behavioral Health Services & Research. 2003;30:462–469. doi: 10.1007/BF02287433. [DOI] [PubMed] [Google Scholar]
  11. Chamberlain P, Reid JB. Comparison of two community alternatives to incarceration for chronic juvenile offenders. Journal of Consulting and Clinical Psychology. 1998;66:624–633. doi: 10.1037//0022-006x.66.4.624. [DOI] [PubMed] [Google Scholar]
  12. Chamberlain P, Reid JB. Using a specialized foster care treatment model for children and adolescents leaving the state mental hospital. Journal of Community Psychology. 1991;19:266–276. [Google Scholar]
  13. Chen H, Reeves JH, Fincham JE, Kennedy WK, Dorfman JH, Martin BC. Off-label use of antidepressant, anticonvulsant, and antipsychotic medications among Georgia Medicaid enrollees in 2001. Journal of Clinical Psychiatry. 2006;67:972–982. doi: 10.4088/jcp.v67n0615. [DOI] [PubMed] [Google Scholar]
  14. Comer JS, Olfson M, Mojtabai R. National trends in child and adolescent psychotropic polypharmacy in office-based practice, 1996-2007. American Academy of Child & Adolescent Psychiatry. 2010;49:1001–1010. doi: 10.1016/j.jaac.2010.07.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Connor DF, Ozbayrak KR, Harrison RJ, Melloni RH. Prevalence and patterns of psychotropic and anticonvulsant medication use in children and adolescents referred to residential treatment. Journal of Child and Adolescent Psychopharmacology. 1998;8:27–38. doi: 10.1089/cap.1998.8.27. [DOI] [PubMed] [Google Scholar]
  16. Constantine RJ, Boaz T, Tandon R. Antipsychotic polypharmacy in the treatment of children and adolescents in the fee-for-service component of a large state Medicaid program. Clinical Therapeutics. 2010;32:949–959. doi: 10.1016/j.clinthera.2010.04.021. [DOI] [PubMed] [Google Scholar]
  17. Crismon ML, Argo T. The use of psychotropic medication for children in foster care. Child Welfare. 2009;88:71–100. [PubMed] [Google Scholar]
  18. Dorsey S, Farmer EMZ, Barth RP, Greene KM, Reid J, Landsverk J. Current status and evidence base of training for foster and treatment foster parents. Children and Youth Services Review. 2008;30:1403–1416. doi: 10.1016/j.childyouth.2008.04.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. dosReis S, Zito JM, Safer DJ, Gardner JF, Puccia KB, Owens PL. Multiple psychotropic medication use for youths: A two-state comparison. Journal of Child and Adolescent Psychopharmacology. 2005;15:68–77. doi: 10.1089/cap.2005.15.68. [DOI] [PubMed] [Google Scholar]
  20. Dean AJ, McDermott BM, Marshall RT. Psychotropic medication utilization in a child and adolescent mental health service. Journal of Child and Adolescen Psychopharmacology. 2006;16:273–285. doi: 10.1089/cap.2006.16.273. [DOI] [PubMed] [Google Scholar]
  21. Essock SM, Covell NH, Leckman-Westin E, Lieberman JA, Sederer LI, Kealyey E, Finnerty MT Members of the Scientific Advisory Committee. Identifying questionable psychotropic prescribing practices for Medicaid recipients in New York State. Psychiatric Services. 2009;60:1595–1602. doi: 10.1176/ps.2009.60.12.1595. [DOI] [PubMed] [Google Scholar]
  22. Farmer EMZ, Angold A, Burns BJ, Costello EJ. Reliability of self-reported service use: Test-retest consistency of children's responses to the Child and Adolescent Services Assessment. Journal of Child and Family Studies. 1994;3:307–325. [Google Scholar]
  23. Farmer EMZ, Burns BJ, Wagner HR, Murray M, Southerland DG. Enhancing “usual practice” treatment foster care: Findings from a randomized trial on improving youths' outcomes. Psychiatric Services. 2010a;61:555–561. doi: 10.1176/appi.ps.61.6.555. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Farmer EMZ, Mustillo SA, Wagner HR, Burns BJ, Kolko DJ, Barth RP, Leslie LK. Service use and multi-sector use for mental health problems by youth in contact with child welfare. Children and Youth Services Review. 2010b;32:815–821. [Google Scholar]
  25. Ferguson DG, Glesener DC, Raschick M. Psychotropic drug use with European American and American Indian children in foster care. Journal of Child and Adolescent Psychopharmacology. 2006;16:474–481. doi: 10.1089/cap.2006.16.474. [DOI] [PubMed] [Google Scholar]
  26. Findling RL, Johnson JL, McClellan J, Frazier JA, Vitiello B, Hamer RM, et al. Double-blind maintenance safety and effectiveness findings from the Treatment of Early-Onset Schizophrenia Spectrum (TEOSS) study. Journal of the American Academy of Child & Adolescent Psychiatry. 2010;49:583–594. doi: 10.1016/j.jaac.2010.03.013. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Fontanella CA, Bridge JA, Campo JV. Psychotropic medication changes, polypharmacy, and the risk of early readmission in suicidal adolescent inpatients. Annals of Pharmacotherapy. 2009;43:1939–1947. doi: 10.1345/aph.1M326. [DOI] [PubMed] [Google Scholar]
  28. Goodman R. Psychometric properties of the Strengths and Difficulties Questionnaire. Journal of the American Academy of Child & Adolescent Psychiatry. 2001;40:1337–1345. doi: 10.1097/00004583-200111000-00015. [DOI] [PubMed] [Google Scholar]
  29. Goodman R, Ford T, Simmons H, Gatward R, Meltzer H. Using the Strengths and Difficulties Questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. British Journal of Psychiatry. 2000;177:534–539. doi: 10.1192/bjp.177.6.534. [DOI] [PubMed] [Google Scholar]
  30. Griffith AK, Huscroft-D'Angelo J, Epstein MH, Singh NN, Huefner JC, Pick R. Psychotropic medication use for youth in residential treatment: A comparison between youth with monopharmacy versus polypharmacy. Journal of Child and Family Studies. 2010;19:795–802. [Google Scholar]
  31. Hawkins RP, Meadowcroft P, Trout BA, Luster WC. Foster family-based treatment. Journal of Clinical Child Psychology. 1985;14:220–228. [Google Scholar]
  32. Efner JC, Griffith AK, Smith GL, Vollmer DG, Leslie LK. Reducing psychotropic medications in an intensive residential treatment center. Journal of Child and Family Studies 2012 [Google Scholar]
  33. Jensen PS, Bhatara VS, Vitiello B, Hoagwood K, Feil M, Burke LB. Psychoactive medication prescribing practices for U.S. children: Gaps between research and clinical practice. Journal of the American Academy of Child & Adolescent Psychiatry. 1999;38:557–565. doi: 10.1097/00004583-199905000-00017. [DOI] [PubMed] [Google Scholar]
  34. Jerrell JM. Neurological and cardiovascular adverse events associated with antimanic treatment in children and adolescents. CNS Neuroscience & Therapeutics. 2009;16:25–31. doi: 10.1111/j.1755-5949.2009.00087.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Jerrell JM, McIntyre RS. Adverse events in children and adolescents treated with antipsychotic medications. Human Psychopharmacology: Clinical and Experimental. 2008;23:283–290. doi: 10.1002/hup.932. [DOI] [PubMed] [Google Scholar]
  36. Leslie LK, Mackie T, Dawson EH, Bellonci C, Schoonover DR, Rodday AM, et al. Hyde J. Multi-state study on psychotropic medication oversight in foster care. Boston, MA: Clinical and Translational Sciences Institute, Tufts University Medical Center; 2010. [Google Scholar]
  37. Malone RP, Sheikh R, Zito JM. Novel antipsychotic medications in the treatment of children and adolescents. Psychiatric Services. 1999;50:171–174. doi: 10.1176/ps.50.2.171. [DOI] [PubMed] [Google Scholar]
  38. Mark TL, Levit KR, Buck JA. Psychotropic drug prescriptions by medical specialty. Psychiatric Services. 2009;60:1167. doi: 10.1176/ps.2009.60.9.1167. [DOI] [PubMed] [Google Scholar]
  39. Mojtabai R, Olson M. National trends in psychotropic medication polypharmacy in office-based psychiatry. Archives of General Psychiatry. 2010;67:26–36. doi: 10.1001/archgenpsychiatry.2009.175. [DOI] [PubMed] [Google Scholar]
  40. Morrato EH, Nicol GE, Maahs D, Druss BG, Hartung DM, Valuck RJ, et al. Newcomer JW. Metabolic screening in children receiving antipsychotic drug treatment. Archives of Pediatrics and Adolescent Medicine. 2010;164:344–351. doi: 10.1001/archpediatrics.2010.48. [DOI] [PubMed] [Google Scholar]
  41. Murray MM, Southerland D, Farmer EM, Ballentine K. Enhancing and adapting treatment foster care: Lessons learned in trying to change practice. Journal of Child and Family Studies. 2010;19:393–403. doi: 10.1007/s10826-009-9310-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Olfson M, Marcus SC, Weissman MM, Jensen PS. National trends in the use of psychotropic medications by children. Journal of the American Academy of Child & Adolescent Psychiatry. 2002;41:514–521. doi: 10.1097/00004583-200205000-00008. [DOI] [PubMed] [Google Scholar]
  43. Olfson M, Blanco C, Liu L, Moreno C, Laje G. National trends in the outpatient treatment of children and adolescents with antipsychotic drugs. Archives of General Psychiatry. 2006;63:679–685. doi: 10.1001/archpsyc.63.6.679. [DOI] [PubMed] [Google Scholar]
  44. Olfson M, Crystal S, Huang C, Gerhard T. Trends in antipsychotic drug use by very young, privately insured children. Journal of the American Academy of Child & Adolescent Psychiatry. 2010;49:13–23. doi: 10.1097/00004583-201001000-00005. [DOI] [PubMed] [Google Scholar]
  45. Olfson M, Marcus SC. National trends in outpatient psychotherapy. American Journal of Psychiatry. 2010;167:1456–1463. doi: 10.1176/appi.ajp.2010.10040570. [DOI] [PubMed] [Google Scholar]
  46. Riddle MA, Kastelic EA, Frosch E. Pediatric psychopharmacology. Journal of Child Psychology and Psychiatry. 2001;42:73–90. [PubMed] [Google Scholar]
  47. Robst J, Armstrong M, Dollard N. Age, race, and gender differences in antipsychotic medication use among children prior to entry to out-of-home care. Residential Treatment for Children & Youth. 2009;26:119–134. [Google Scholar]
  48. Rushton JL, Whitmire JT. Pediatric stimulant and selective serotonin reuptake inhibitor prescription trends, 1992 to 1998. Archives of Pediatrics and Adolescent Medicine. 2001;155:560–565. doi: 10.1001/archpedi.155.5.560. [DOI] [PubMed] [Google Scholar]
  49. Ryan JB, Reid R, Gallagher K, Ellis C. Prevalence rates of psychotropic medications for students placed in residential facilities. Behavioral Disorders. 2008;33:99–107. [Google Scholar]
  50. Safer DJ, Zito JM, dosReis S. Concomitant psychotropic medication for youths. American Journal of Psychiatry. 2003;160:438–449. doi: 10.1176/appi.ajp.160.3.438. [DOI] [PubMed] [Google Scholar]
  51. StataCorp. Stata Statistical Software: Release 11. College Station TX: StataCorp LP; 2009. [Google Scholar]
  52. Swanson J, Arnold LE, Kraemer H, Hechtman L, Molina B, Hinshaw S, et al. MTA Cooperative Group. Evidence, interpretation, and qualification from multiple reports of long-term outcomes in the Multimodal Treatment Study of Children with ADHD (MTA): Part II: Supporting details. Journal of Attention Disorders. 2008;12:15–43. doi: 10.1177/1087054708319525. [DOI] [PubMed] [Google Scholar]
  53. Treatment for Adolescents with Depression Study (TADS) Team. The Treatment for Adolescents with Depression Study (TADS): Long-term effectiveness and safety outcomes. Archives of General Psychiatry. 2007;64:1132–1144. doi: 10.1001/archpsyc.64.10.1132. [DOI] [PubMed] [Google Scholar]
  54. Walkup JT, Albano AM, Piacentini J, Bimaher B, Compton SN, Sherrill JT, et al. Kendall PC. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine. 2008;359:2753–2766. doi: 10.1056/NEJMoa0804633. [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Walkup J The AACAP Work Group on Quality Issues. Practice parameter on the use of psychotropic medication in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry. 2009;48:961–973. doi: 10.1097/CHI.0b013e3181ae0a08. [DOI] [PubMed] [Google Scholar]
  56. Zima BT, Bussing R, Crecelius GM, Kaufman A, Belin TR. Psychotropic medication treatment patterns among school-aged children in foster care. Journal of Child and Adolescent Psychopharmacology. 1999;9:135–147. doi: 10.1089/cap.1999.9.135. [DOI] [PubMed] [Google Scholar]
  57. Zito JM, Safer DJ, dosReis S, Gardner JF, Magder L, Soeken K, et al. Riddle MA. Psychotropic Patterns for Youth: a 10-year perspective. Archives of Pediatrics and Adolescent Medicine. 2003;157:17–25. doi: 10.1001/archpedi.157.1.17. [DOI] [PubMed] [Google Scholar]
  58. Zito JM, Safer DJ, Sai D, Gardner JF, Thomas D, Coombes P, et al. Mendez-Lewis M. Psychotropic medication patterns among youth in foster care. Pediatrics. 2008;121:e157–e163. doi: 10.1542/peds.2007-0212. [DOI] [PubMed] [Google Scholar]
  59. Zito JM, Safer DJ, Valluri S, Gardner JF, Korelitz JJ, Mattison DR. Psychotherapeutic medication prevalence in Medicaid-insured preschoolers. Journal of Child and Adolescent Psychopharmacology. 2007;17:195–203. doi: 10.1089/cap.2007.0006. [DOI] [PubMed] [Google Scholar]

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