Prescribing psychotropic medicines can have serious health side-effects for all people and especially on youth, whose bodies are still developing. For vulnerable populations like foster youth, bureaucratic processes, health care policies, and state legislation can have a large effect on access, over-prescription, and health screening that could protect them from negative health risks of prescription drugs. Researchers conducted a ten-year analysis of how oversight strategies in California’s foster care system affected prescribing and monitoring processes for antipsychotics drugs. They found that policy changes in California have reduced antipsychotic prescriptions for foster youth by 56.3%, but 82.5% of newly prescribed youth did not receive screening for metabolic harms, despite it being required by the policy.
“Among [psychotropic medications], anti-psychotic medications stand out because of their significant metabolic side effects, including weight gain and predisposition to diabetes mellitus type 2 (Allaire et al, 2016; Skinner et al, 2015). The risk–benefit ratio for the use of antipsychotics may not be in the best interest of foster youth, particularly when other trauma-informed multidisciplinary interventions, such as psychotherapy, may be more effective but are frequently inaccessible to this population (Larsen et al, 2018; Leslie et al, 2004).”
The authors of the 2011-2020 analysis, Julio C. Nunes, MD, Toni Naccarato, MSW, PhD, and Randall S. Stafford, MD, PhD, describe psychotropic medications as “medications prescribed to affect the central nervous system to treat psychiatric disorders or illnesses.” This includes antipsychotic medications, antidepressants, mood stabilizers, medications for dementia and Parkinson’s disease, and many other drugs. Scholars and providers have expressed concerns that psychotropic medications are over-prescribed, especially to children in the foster care system. Foster children are prescribed psychotropic medications roughly four to five times as often as children enrolled in Medicaid.
Several ethical issues exist in the prescription of psychoactive medications to foster children in particular. As quoted above, the medications pose health risks for children when there may be other, less risky interventions available. Second, foster children may be encouraged to take medications under coercive or exploitative situations. Third, the authors cite evidence that housing is sometimes dependent on children accepting and continuing to take medications. Worse yet, despite laws against using these medications as a form of restraint or discipline for children, these situations may still happen.
“Factors that may contribute to the over- prescribing of psychotropic medications to foster youth may include lack of understanding of the effects of childhood trauma, caregiver demand for medication to manage disruptive behaviors, lack of pediatric mental health resources, and misdiagnosis of trauma symptoms as mental health disorders (Szilagyi et al, 2015; Webb, 2013).”
In 2011, the California Department of Social Services implemented the California state-wide Quality Improvement Project (CQIP) designed to “improve safe and appropriate prescribing and monitoring techniques of psychotropic medication use among children and youth in foster care” (according to the California Department of Social Services website). CQIP implemented changes gradually 2013-2016 and released a publication reporting results in 2018: The California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care. The state senate then made many of these recommendations mandatory.
Nunes, Naccarato, and Stafford analyzed CPIQ’s open-source data on a quarterly basis to 1) evaluate the impact of policy changes from 2011-2020 on prescription of psychotropic drugs to foster youth and 2) trends in screening (or not screening) youth for metabolic disorders (given that psychotropic medication increases metabolic risks).
Screening policies added during the CQIP process included blood glucose and cholesterol tests for youth prescribed two or more antipsychotic medications. Screenings were supposed to occur from 90 days prior to 15 days after beginning use of a medication and on an ongoing basis. By 2014, the project required preauthorization using Treatment Authorization Request (TAR) forms for all youth prescribed psychotropic or antipsychotic drugs.
The authors analyzed prescription rates by demographic group, metabolic screening rates, and the number of youths correctly screened. They found a gradual 56.3% decline in prescription of antipsychotic medications from 2011 and 2020 amongst foster children. There were no noticeable sex differences in decline. The lowest declines in antipsychotic prescription were for older youth (age 16-17), Asian and/or Pacific Islander youth, and youth located in Northern California. The largest declines in antipsychotic prescription were for youth under 10 years old and Latinx youth.
Adherence to CQIP’s policies was dubious. In 2020, 32.2% of foster youth did not have necessary TAR forms, 48.8% were not given required metabolic screening, and 82.5% of newly prescribed youth did not receive required metabolic screening. Screening did not vary by demographic variables (race/ethnicity, age groups, geographic subregion, placement type, sex at birth, nor length of time in foster care).
Nunes, Naccarato, and Stafford conclude that CQIP had a positive impact: decreasing prescriptions of antipsychotic drugs to foster youth and increasing metabolic screening. However, compliance with documentation and screening requirements is still incredibly inadequate. Many children continued to receive medications that are likely to have negative metabolic effects without those effects being monitored.
The study demonstrated declines in psychotropic prescription in 2016 followed by increases in 2019 and 2020 for prescriptions for psychotropic drugs in general, indicating prescribers may be substituting other drugs for antipsychotic medication.
“This finding suggests that prescribers may be substituting antipsychotics for other drugs, which may reflect increased awareness regarding appropriate indications and risks of using antipsychotics. Since 2008, several publications have suggested leaving antipsychotics as second-line options for agitation in pediatric populations, culminating in the American Association for Emergency Psychiatry guidelines (2019) (Gerson et al, 2019).”
The authors interpret low rates of decline in specific populations (i.e., 16–17-year-olds, Asian and/or Pacific Islander youth) as a potential sign that those populations need more improvements in legislation. An alternate explanation is that those populations were being appropriately prescribed instead of over-prescribed prior to the program’s implementation. These possibilities would need to be explored to make appropriate decisions about future legislation.
An acknowledged limitation of this study is the absence of information about youths’ diagnoses, symptoms, or results of the pharmaceutical intervention. This makes it difficult to understand which youth were prescribed medicines designed for their diagnoses or symptoms, as well as whether or not medications worked.
This study would also benefit from deeper analysis of specific populations within their pre-existing contexts. For instance, are there socio-economic differences impacting psychological interventions available to different youth populations? What evidence already exists about which populations are over-prescribed antipsychotics when symptoms are taken into account?
Overall, this study provides important insights about the effect of public health policies and prescribing processes on mental and physical health for foster youth. Its methods provide an example of checking the impacts of legislation, while drawing attention to ethically questionable practices and poor preventative health care provided to foster youth.
Nunes, J. C., Naccarato, T., & Stafford, R. S. (2022). Antipsychotics in the California Foster Care System: A 10-Year Analysis. Journal of Child and Adolescent Psychopharmacology, 32(7), 400–407. https://doi.org/10.1089/cap.2022.0040 (Full text)