Psychotropic Medication Management for Youth in State Care: Consent, Oversight, and Policy Considerations
Naylor, Michael W., Davidson, Christine V., Ortega-Piron, D. Jean, Bass, Arin, Gutierrez, Alice, Hall, Angela, Child Welfare
The use of psychotropic medications in youth with emotional disturbances in state custody is increasing and presents unique challenges concerning consent and oversight. We examine various means that state child welfare agencies use to provide consent for and oversight of psychotropic medications for children in state custody and describe benefits of a consent process that provides for expert consultation to the child welfare agency and prescribing clinicians, case-specific and systemic oversight of psychotropic medication use, and education for stakeholders.
With few exceptions, youth in foster care have been physically or sexually abused, neglected, or both. A significant body of literature shows that children in foster care are at higher risk for developing emotional and behavioral disturbances and mental illness (McIntyre & Keesler, 1986; Trupin, Tarico, Low, Jemelka, & McClellan, 1993; Harman, Childs, & Kelleher, 2000; dosReis, Zito, Safer, & Soeken, 2001; Burns et al., 2004) than youth from comparable backgrounds. Reflective of their high rates of mental illness and emotional disturbances, children and adolescents in substitute care (by definition eligible for Medicaid benefits) use mental health services at higher rates than other Medicaid-eligible youth (Halfon, Berkowitz, & Klee, 1992; Harman et al., 2000; dos Reis et al., 2001). Furthermore, children and adolescents in substitute care are more likely to receive psychotropic medications than other Medicaid eligible youth (dos Reis et al., 2001; Raghavan, Zima, Anderson, Leibowitz, Schuster, & Landsverk, 2005). Indeed, up to 13.5% of children and adolescents in foster care are prescribed psychotropic medications (Zima, Bussing, Crecelius, Kaufman, & Belin, 1999; Raghavan et al., 2005). Level of care predicts the use of psychotropic medications. Youth in group homes are significantly more likely to be prescribed psychotropic medications than those in therapeutic foster care (Breland-Noble, Elbogen, Farmer, Dubs, Wagner, & Burns, 2004).
The use of psychotropic medications for the treatment of youth with severe emotional and behavioral disturbances has increased dramatically over recent years. Zito et al. (2003) reported a two- to threefold increase in the prevalence of psychotropic medications between 1987 and 1996, with particularly rapid growth in prescribing a-agonists such as clonidine and guanfacine, antipsychotic medications, and anticonvulsant medications prescribed as mood stabilizers. They concluded that the rate of prescribing psychotropic medications for children and adolescents is approaching that seen in the adult population.
The increasing use of psychotropic medications is paralleled by a two-point-five- to eight-fold increase in the rate of polypharmacy, the coadministration of two or more psychotropic medications, between the late 1980s and the late 1990s (Olfson, Marcus, Weissman, & Jensen, 2002; Safer, Zito, & dos Reis, 2003; Bhatara, Feil, Hoagwood, Vitiello, & Zima, 2004). Anderson and colleagues found that the rate of polypharmacy in children in foster care in Illinois increased between the mid 1990s and the early 2000s (Anderson, Naylor, Kruesi, & Stoewe, 2002). Higher rates were reported for children and adolescents treated in psychiatric hospitals and residential centers and for youth in foster care (Safer et al., 2003; Bhatara et al., 2004). Combining psychostimulants and antidepressants is particularly common (Olfson et al., 2002; Bhatara et al., 2004).
Research supporting the practice of polypharmacy in the pediatric population is sparse. While recent reports have been published in the child and adolescent psychiatric literature supporting specific psychotropic medication combinations (Delbello, Schwiers, Rosenberg, & Strakowski, 2002; Aman, Binder, & Turgay, 2004; Pavuluri, Henry, Carbray, Sampson, Naylor, & Janicak, 2006), most of these are case series or open-label trials. …