Understanding the Use of Psychotropic Medications in the Child Welfare System: Causes, Consequences, and Proposed Solutions

By Alavi, Zakia; Calleja, Nancy G. | Child Welfare, March/April 2012 | Go to article overview

Understanding the Use of Psychotropic Medications in the Child Welfare System: Causes, Consequences, and Proposed Solutions


Alavi, Zakia, Calleja, Nancy G., Child Welfare


Recent studies have highlighted the progressively increasing number of children prescribed psychotropic medication, while findings have illustrated significantly greater usage among child welfare-involved children. These findings have raised serious concerns among mental health and child welfare professionals as well as the general public. To address this issue, the authors explore the factors that may contribute to the higher incidence of psychotropic medication usage among child welfare-involved children and the unintended negative consequences for these children and the public health system. They propose methods to effectively address this problem.

The diagnosis of Axis I psychiatric disorders and the concomitant use of psychotropic medications in children has increased dramatically in children in the United States over the last two decades. In fact, the annual prevalence rate of psychotropic medication use in youth in the U. S. is 6.7%, compared to 2.9% in the Netherlands and 2% in Germany (Zito et al., 2008) and the Food and Drug Administration (2009) recently found that more than 500,000 American children and adolescents are specifically taking antipsychotic drugs. Some attribute this increase to better diagnostic tools and a decrease in stigma associated with mental illness. Others have voiced growing concerns that this is a result of over-prescribing, indiscriminately and excessively (Dean, McDermott, 6c Marshall, 2006; Zakriski, Wheeler, Burda, 6c Shields, 2005).

Within the child welfare system, this issue has become even more contentious because of the significantly higher rate of psychotropic medication seen in this population. In fact, several studies show rates of medication use for children in child welfare ranging from 13% to 37% (Raghavan, et al., 2005), compared to 4% in youth among the general population (Cox, Motheral, Henderson, 6c Mager, 2003; Olfson, Marcus, Weissman, 6c Jensen, 2002). Additionally, within the child welfare population, higher rates are seen in children who have been placed in restrictive care settings such as the juvenile justice system and residential treatment programs or child caring institutions (Zito et al., 2008).

At this point, several studies have been conducted to examine the prevalence of psychotropic medication use among children (Zima, Bussing, Crecelius, Kaufman, 6c Belin, 1999; Zito et al., 2008). Professional organizations such as the American Academy of Child and Adolescent Psychiatry (AACAP, 2001) have responded with detailed guidelines and practice parameters for their specialties and the AACAP and the Child Welfare League of America have issued a joint policy statement (2003). Finally, a 2009 special issue of Child Welfare (see Volume 88, Number 1) dedicated to children's mental health further highlights the prominence of this issue today. Each of these actions has led to an increased emphasis on this issue, and each action has been motivated by a need to better understand and/or address this issue. In order to continue to meet these objectives, we will:

1. Examine and categorize the causes of this increased prevalence of psychotropic medication use;

2. Examine the unintended, negative consequences of this phenomenon for foster children and the public health system; and

3. Propose methods to effectively address this problem.

Contributing Factors

Biological Vulnerability of Foster Children

Besides maltreatment, genetic and prenatal toxic factors impacting the development of foster children have to be considered.

Prenatal exposure to toxins. In the United States, parental substance abuse is one of the most frequent causes of foster placement. In fact, in 2004, the National Center on Addiction and Substance Abuse of Columbia University found that seven out of 10 abused or neglected children had substance addicted parents (Oswald, Heil, 6c Goldbeck, 2010). According to a report from NCCP, nearly 80% of children in foster care have prenatal exposure to substances (Cooper, Banghart, 6c Aratani, 2010) Numerous well-designed studies indicate that specific learning and behavior problems may result from prenatal exposure to tobacco and illicit drugs in combination with negative environmental conditions postpartum. …

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