Editor's Note:
A recent study[1] by investigators in the PolicyLab at The Children's Hospital of Philadelphia (CHOP) that was conducted at the request of the Pennsylvania Department of Human Services found startling rates of use of antipsychotics and polypharmacy in Medicaid-enrolled children aged 3-18 years. The analysis was conducted amid growing concerns about the safety and efficacy of psychotropic medications in children. Some key findings of the report include:
For youth aged 6-18 years in 2012, the use of psychotropic medications was nearly three times higher among youth in foster care than youth in Medicaid overall (prescribed in 43% vs 16%).
The use of antipsychotics was four times higher among youth in foster care than youth in Medicaid overall (22% vs 5%). More than one half of youth in Medicaid who used antipsychotics had a diagnosis of attention-deficit/hyperactivity disorder. This is concerning, because most of these youth did not have another diagnosis that clinically indicated the use of antipsychotics, a medication class with significant side effects.
Polypharmacy, the use of multiple classes of medications in combination, occurred at a rate four times higher among youth in foster care than all youth in Medicaid (12% vs 3%).
Youth in foster care were more likely to have not received any visits within a year of seeing a provider for their behavioral health concerns while on psychotropic medications.
The investigators used state Medicaid data from 2007-2010 and 2012 and the results are specific to Pennsylvania children, although the study raises questions about use of these agents in children living in similar circumstances nationwide.
Medscape spoke with three of the investigators about the implications of the study. Meredith Matone, MHS, is a research scientist who addressed the public health implications. Kathleen Noonan, JD, founding codirector of PolicyLab, provided insights on the legal and policy implications of the study. David Rubin, MD, MSCE, founding codirector of PolicyLab and professor of pediatrics at the Perelman School of Medicine at the University of Pennsylvania, offered a perspective on the key clinical messages for pediatric healthcare professionals.
Is Drug Overuse a Problem in All Kids, or Just Poor Kids? ...
Medscape: This very important study from PolicyLab looked at the use of psychotropic agents in Medicaid-eligible children (as a proxy marker for children living in poverty). Are there comparable data for children in other socioeconomic groups—privately insured or underinsured children—or is this a problem unique to the population of children that they studied?
Dr Rubin: The rates of use of psychotropic drugs have been going up for all kids, but the rates among those who are publicly insured are clearly higher than for privately insured children. There are probably many reasons for that, but first and foremost, the privately insured kids often have much greater access to other therapies, including counseling and other therapy services that are not widely available to publicly insured children. Those types of therapies act as a competitive buffer to reduce the rate of antipsychotic use. When antipsychotics are the only tool in the toolbox, you end up seeing disproportionately much higher rates of use of those medications, particularly when children are presenting with disruptive or aggressive behaviors.
Ms Noonan: From a policy/legal perspective, we were particularly interested in the Medicaid population, because what we wanted to understand is the unique medication issues among youth in foster care, most of whom are publicly insured in the Medicaid program. Although it is true that rates of use of psychotropic medications have increased for all children, the rates in foster care are dramatically elevated—which is a concern from a legal perspective, because these children do not always have the benefit of a parent or guardian's involvement when these decisions are made.
As part of our portfolio of work on psychotropic medication at PolicyLab, we conducted a policy analysis to determine whether law or policy contributes to higher rates of psychotropic medication use among children in foster care, and more specifically, whether there are insufficient legal and policy protections for these youth. Our analyses of policies and laws in this area found that few states had put in place rules related to the use of psychotropic mediations in children; the use of multiple medications; the use of medications in very young children; or the identification of prescribing red flags, such as the use of antipsychotics for a nonindicated condition.
Ms Matone: Research demonstrates that prescription of antipsychotic medications is more frequent among publicly insured youth than among privately insured youth. Although medication use among uninsured and underinsured youth is difficult to study, it is likely that access to needed behavioral healthcare is a challenge for these youth.
A Population Health Issue
Medscape: Other than the data showing that these drugs are disproportionately used in publicly insured children, what are the key implications from this study?
Dr Rubin: Too often, children who are in publicly funded mental health systems are receiving reactive treatment. They are seeing providers who have very few resources to offer the family other than the immediate sedation provided by the antipsychotic.
We can focus on restricting authorization for antipsychotics, but at the end of the day, we are not going to get ourselves out of this crisis without a serious discussion about trying to provide other therapies for children who have been traumatized—either maltreated or victimized in some way, through emotional neglect or psychological trauma—and are presenting with behavioral issues. If we don't start to build capacity for the types of programs and services that have a fairly strong evidence base but are woefully underfunded, we are leaving providers and families handicapped with respect to interventions.
Ms Noonan: We are concerned that doctors are turning to psychotropic medications because they are more readily available and easier to access than nonpharmacologic interventions. These medications with less evidence behind them are more plentiful than proven therapies. We consider this a market failure that will require government intervention to correct. Policies that support greater rigor regarding the use of medications will help, but what the market really needs is better and more readily accessible therapies.
Ms Matone: From a public health perspective, this study describes a true population health issue. The large number of youth exposed to psychotropic medications reflects a need for systems-level solutions to the delivery of appropriate behavioral health services. Underlying the high rates of psychotropic medication use are a variety of behavioral health needs, ranging in severity from poor behavioral control to psychiatric illness—and, in the case of children in foster care, symptoms related to exposure to trauma. At the systems level, delivery of services must meet these diverse needs, and the use of psychotropic medications should be one therapeutic option, not the primary option.
The Missing Link: Care Integration
Medscape: Are those lessons equally applicable to children who may be out of the foster care system but still experience frequent disruptions in their living situations—children whose families move frequently, or children who move from one family member to another?
Dr Rubin: Absolutely. Those children are uniquely exposed to a tremendous amount of trauma in their lives—the trauma of separation, failure, and attachment issues. The proportion of children who manifest their trauma with serious aggression or disruptive behaviors is much higher than that among children with more stability.
Through identification in a new school or another avenue, children with residential instability are more likely to be seen by a provider and present for an evaluation. Therefore, they are more likely to be exposed to psychotropic medications. Disruptions in living situations and providers (who may only see the child once) compound this challenge, because providers who do not have a long-term relationship with a child may be more likely to continue labeling him or her in a certain way or be less likely to try to discontinue a medication.
Medscape: Clinicians may have a hard time addressing some of the system inadequacies that you mentioned, such as underfunding. What concrete steps would you suggest to clinicians? For example, should a primary care provider attempt to provide care for these kids, including prescribing when deemed appropriate, or is this simply a strong message to work collaboratively with mental health professionals?
Dr Rubin: There is a real push in healthcare toward better integration—whether it's accountable care organizations or integration with behavioral health and primary care. In this environment, it's no longer an acceptable practice to just tell a family that they need to go see a mental health provider and leave it up to them to try to figure out how to do that. Clinicians cannot fix the inequities in the system because they are busy practicing every day, but at the very least, all clinicians should recognize just how many children are exposed to trauma, and how many children are being exposed to these medications.
Anyone who is practicing primary care, whether or not they go to the full extent of truly integrating behavioral health providers into their practices, should at the very least create a resource map of provider services in their area and try to create better conduits through which they can participate in some level of integrated care for these children, even if that child is disruptive and moving through multiple homes. If clinicians don't have the time or the capability to have true behavioral health integration in the practice, they can still develop a resource map. They can identify a trusted provider or two, try to create mechanisms of direct referral and feedback, and think outside the box about alternative strategies to help that child.
The same goes for community-based services—whether it's infant home visitation services for young mothers who are struggling to raise their infants to try to break that cycle of trauma, or other community-based referrals.
Ms Noonan: This is not a story about bad doctors; it's about limited resources. Some children need medication, but medication should be used after other therapies have failed or as a complement to therapies. We need pediatricians at the table when these policy and resource decisions are made. Their experiences with families and children must shape the policy discussion about the appropriate use of medications.
Ms Matone: Psychotropic medications play an important role in the treatment of psychiatric illness. For youth presenting with behavioral symptoms, the use of psychotropic medications should be considered carefully, and for youth in foster care, behavioral symptoms should be considered in the context of exposure to trauma. Evidence-based and trauma-informed nonpharmacologic therapies, such as parent/child interaction therapy, may be a well-suited alternative to medication. Innovative solutions to behavioral healthcare access, including colocation of behavioral health providers within primary care or child welfare agencies, may improve availability of these services.
Medscape: Would you like to add anything in your message to clinicians?
Dr Rubin: I acknowledge that every clinician is in a different place in terms of their level of involvement. Practices are busy, with a high volume of patients. I do think, however, that there are contributions that every provider can make no matter where they are.
Providers can begin to integrate with preferred providers or, if the issue moves them, they can become more engaged with these issues. Our failure to participate more in this issue means that we are really only scratching the surface of what it will take to improve outcomes among the many children exposed to a high degree of trauma. We are potentially exposing them to harm. That is a real challenge for everyone, wherever they are—to expect a little more out of themselves in terms of this push toward integration and better services for children.
Editor's Note: In spring 2015, the PolicyLab at CHOP issued an Evidence to Action brief that provides an in-depth look at antipsychotic medication prescribing in children receiving Medicaid and in foster care. The document reviews what is known about this issue and why it matters; and, importantly, it provides suggestions about what can be done.
