This project has results

Examining the Effects of Four State Policies to Monitor the Use of Antipsychotics in Children in Foster Care

Results Summary and Professional Abstract

Results Summary

What was the research about?

Doctors sometimes give children medicines to treat mood and behavior problems. These medicines include antipsychotics, which help treat conditions like schizophrenia. Antipsychotics are also sometimes used to treat more common conditions like attention-deficit/hyperactivity disorder, or ADHD. But these medicines can have long-term risks like heart attack and diabetes. Children in foster care get these medicines more often than other children.

States oversee the care of youth in foster care, including what medicines they get. In the study, the research team looked at policies for managing antipsychotic use in four states:

In some Ohio counties, doctors got a guide for prescribing antipsychotics. The guide also suggested how to manage these medicines so children would not get more than one antipsychotic at once.
In some Wisconsin counties, a policy improved coordination of medical and mental health care.
In Washington, the state required doctors to get permission from child psychiatrists to prescribe antipsychotics.
In Texas, doctors got guidance on prescribing antipsychotics. Texas also suggested that doctors test for the side effects of antipsychotics.

The research team looked at how the state programs affected how and when children in foster care got antipsychotics.

What were the results?

Overall, the policies helped improve the way antipsychotics were used for children in foster care.

Ohio: Compared with children not in foster care, children in foster care were less likely to get multiple antipsychotics.

Wisconsin: Rates of blood testing for side effects of antipsychotics for children in foster care in participating counties went up compared with children in other counties.

Washington: Rates of antipsychotic use went down more in children in foster care than in children not in foster care.

Texas: Compared with adopted children, children in foster care

Were less likely to get antipsychotics when they had conditions like ADHD and depression
Got blood tests to check for side effects at about the same rates

Also, children in foster care on antipsychotics in Texas had greater increases in blood testing than children in Ohio, which had no testing guidance.

Who was in the study?

The study included health records for children in foster care in four states. All children had Medicaid and a mental health condition that doctors sometimes treated with antipsychotics.

What did the research team do?

The research team examined four state policies that monitor how children in foster care get antipsychotics. Using Medicaid health records, the team identified which medicines children in foster care got. The team also looked at whether children in Texas and Wisconsin had blood tests for antipsychotics’ side effects.

Adults who were once in those states’ foster care systems, foster caregivers, social workers, doctors, and pharmacists helped plan the study.

What were the limits of the study?

Results may differ for other states and policies. Findings may have differed if the research team used interviews or surveys instead of health records.

Future research could look at antipsychotic prescription in other states, or at other kinds of information from children like quality of life.

How can people use the results?

State policy makers can use these results when considering policies on antipsychotics for children in foster care.

Professional Abstract

Objective

To examine the effects of state antipsychotic prescription strategies for children in foster care (FC) on antipsychotic prescriptions and side effects among those children

Study Design

Design Elements	Description
Design	Observational: cohort study
Population	In Ohio (13 counties), Wisconsin (six counties), and Washington (entire state), study compared all children who were receiving Medicaid and who were in FC with children who were not in FC; in Texas, study compared all children who were receiving Medicaid and who were in FC with children who were adopted with children who were adopted
Interventions/ Comparators	Four state antipsychotic prescription strategies in Ohio, Wisconsin, Washington, and Texas
Outcomes	Prevalence of antipsychotic polypharmacy in children in FC (Ohio); antipsychotics prescribed to children in FC (Texas and Washington); metabolic testing rates for children in FC (Texas and Wisconsin)
Timeframe	Up to 9-year follow-up for study outcomes

Researchers examined interventions that monitor antipsychotic prescriptions for children in FC in four states:

Ohio (13 counties): A providers’ guide on antipsychotic prescribing with a focus on polypharmacy, or the use of multiple antipsychotics
Wisconsin (six counties): Integration of medical and mental health services for children in FC
Washington: Prior authorization for antipsychotic prescriptions for children in FC based on review from child psychiatrists
Texas: Prescribing parameters for children in FC plus metabolic management to monitor side effects

The study included children receiving Medicaid in four states. Researchers examined Medicaid claims data before and after the implementation of the interventions to identify differences in outcomes for children in FC versus children not in FC with similar mental health conditions. In each state, researchers examined different outcomes and used different comparison groups.

Adults previously in FC, foster caregivers, social workers, doctors, and pharmacists helped plan the study.

Results

Ohio: Compared with children not in FC, children in FC had significantly greater decreases in polypharmacy rates from pre- to post-implementation. Children in FC had significantly higher polypharmacy rates at both time points (p<0.05).

Wisconsin: Metabolic testing rates improved significantly for children in FC on antipsychotics in pilot counties from pre- to post-implementation; rates were stable in non-pilot counties (95% confidence interval [CI] = 1.2, 19.7).

Washington: Initially, compared with children not in FC, rates of antipsychotic use declined less for children in FC. In the second year after implementation, rates of antipsychotic use declined significantly faster among children in FC.

Texas:

Compared with adopted children with conditions often treated with antipsychotics such as autism or bipolar disorder, children in FC with those conditions showed no significant differences in medications dispensed.
Children with externalizing conditions like attention-deficit/hyperactivity disorder and children with internalizing conditions like depression had significantly larger decreases than adopted children in the number of antipsychotics dispensed after implementation (p<0.05).
Compared with adopted children, metabolic testing rates were similar among children in FC with any diagnosed condition; rates increased significantly among both groups after the intervention was implemented.
Compared with children in FC who were treated with antipsychotics in Ohio (which had no intervention to increase metabolic monitoring), children in FC who were treated with antipsychotics in Texas had significantly greater increases in metabolic monitoring (95% CI = 0.02, 1.37).

Limitations

Researchers examined antipsychotic prescription strategies in four states. Results may differ in other states. Findings may have differed if researchers had measured outcomes using different data sources.

Conclusions and Relevance

The antipsychotic prescription policies studied improved appropriate use of antipsychotics for children in FC. State and local policy makers can use this research when considering antipsychotic prescription strategies for youth in FC.

Future Research Needs

Future research could study the effects of other antipsychotic prescription strategies. Researchers could also verify results using different data sources and client-centered outcomes such as quality of life.

This project's final research report is expected to be available by July 2021.

Journal Articles

Journal of the American Academy of Child & Adolescent Psychiatry

Antipsychotic Use Among Youth in Foster Care Enrolled in a Specialized Managed Care Organization Intervention

Pediatrics

Benzodiazepine Treatment and Fracture Risk in Young Persons With Anxiety Disorders

Health Services Research

Effectiveness of mandatory peer review to reduce antipsychotic prescriptions for Medicaid-insured children

American Journal of Preventive Medicine

Prescription Benzodiazepine Use in Privately Insured U.S. Children and Adolescents

Health Affairs

Rapid Growth Of Antipsychotic Prescriptions For Children Who Are Publicly Insured Has Ceased, But Concerns Remain

Evidence for Decisions

Antipsychotic Treatment for Children with Hyperactivity or Conduct Disorders
Clinicians often prescribe antipsychotics for children and adolescents diagnosed with attention deficit hyperactivity disorder (ADHD) or disruptive, impulse-control, and conduct disorders (DICDs). New evidence on the benefits and harms of this treatment can help with decisions about these drugs.

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.

Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:

The reviewers expressed concern that the study described itself as a comparative effectiveness study of state interventions, but most of the analyses involved changes within individual states’ medication oversight programs. The reviewers asked the researchers to acknowledge the limited amount of comparisons they could make across states given the observational nature of this study. The researchers agreed that there were limitations in what comparative conclusions they could draw, and noted that a more experimental model, where children in foster care would be assigned randomly to different interventions, was not feasible. The researchers pointed out that the topic and need for better information would benefit from the type of large-scale data collection, quasi-experimental studies like this one. They expanded the report’s discussion to describe the types of inferences about between-state comparisons that could and could not be made in this type of study.
The reviewers questioned the report’s description of patient and stakeholder engagement. They asked for clarification on the role of stakeholders in developing the project and interpreting results. They asked why stakeholders were not listed as authors of the report. The reviewers also questioned why current children in foster care were not included as study stakeholders. The researchers said they involved patients and families extensively in developing research aims, choosing and prioritizing outcomes, and interpreting results. The researchers said they did not engage stakeholders in writing the report because the writing took place after the budget period of the project. Further, the researchers noted that there were state policy issues with having minors in foster care participate in research studies related to guardianship. In addition, the researchers hesitated to involve minors in the study given the sensitive topics that would be raised in discussions. The researchers ultimately felt that choosing to work with foster care alumni was more appropriate as well as more feasible while still providing a high level of insight into the foster care experience.

Conflict of Interest Disclosures

The COI disclosure form will be posted here soon.

Project Details

Principal Investigator

Stephen Crystal, PhD, MS

Project Status

Completed; PCORI Public and Professional Abstracts Posted

Project Title

Comparative Effectiveness of State Psychotropic Oversight Systems for Children in Foster Care

Board Approval Date

April 2015

Project End Date

September 2020

Organization

Rutgers University–New Brunswick

Year Awarded

2015

State

New Jersey

Year Completed

2020

Project Type

Research Project

Health Conditions

Mental/Behavioral Health

Addiction/Substance Abuse

Depression

Serious Mental Illness

Post Traumatic Stress Disorder

Nutritional and Metabolic Disorders

Diabetes

Intervention Strategies

Behavioral Interventions
Other Clinical Interventions
Other Health Services Interventions
Policy Interventions
Technology Interventions
Training and Education Interventions

Populations

Children -- 18 and under
Low Income
Racial/Ethnic Minorities

Funding Announcement

Improving Healthcare Systems

Project Budget

$2,367,340

Study Registration Information

HSRP20153585

Page Last Updated:

November 6, 2020