Results Summary

What was the research about?

Doctors sometimes give children medicine called antipsychotics that can affect mood and behavior. Antipsychotics can have long-term risks, like heart attack and diabetes, but they help treat serious conditions like schizophrenia. But children may also receive antipsychotics to treat other conditions, like attention deficit hyperactivity disorder. The Food and Drug Administration, or FDA, has not approved antipsychotics for these types of mental health problems. Children in foster care get these medicines more often than children not in foster care.

States are responsible for children in foster care, including what medicines they get. In this study, the research team looked at policies to improve antipsychotic use in four states:

  • In some Ohio counties, doctors got prescribing guidance that included reducing the use of multiple antipsychotics at once.
  • In some Wisconsin counties, a policy improved coordination of medical and mental health care.
  • In Washington, the state required doctors to get approval from psychiatrists to prescribe antipsychotics.
  • In Texas, doctors got guidance on prescribing antipsychotics. The guidance also suggested testing for side effects of antipsychotics.

The team looked at how the state policies and programs affected antipsychotic use for children in foster care.

What were the results?

Overall, the policies improved appropriate use of antipsychotics for children in foster care.


  • There were reductions in use of more than one antipsychotic at the same time. Children in foster care had the largest reductions


  • Rates of recommended blood tests improved for children in foster care


  • Before the state required reviews by psychiatrists, rates of antipsychotic medicines in Washington were similar to other states. Two years after the new policy, rates declined in Washington but stayed the same in the comparison states. Rates went down more among children in foster care than children not in foster care


  • Compared with adopted children, those in foster care with less severe conditions where the FDA does not recommend antipsychotic treatment were less likely to get those prescriptions
  • Treatment rates didn’t change for children with more severe problems, where the FDA does recommend treatment.
  • Rates of blood tests for safety monitoring increased among children in foster care and adopted children.

What did the research team do?

The team looked at states with policies that affect how children in foster care get antipsychotics. All children had Medicaid. Using 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.

Young adults who were once in foster care, caregivers of children in foster care, social workers, and doctors gave input on the study.

What were the limits of the study?

The study looked at policies in four states. 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 policies in other states, or at other kinds of information from children, like quality of life.

How can people use the results?

Policymakers can use these results when considering how to improve antipsychotic prescribing for children in foster care.

Final Research Report

View this project's final research report.

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

Project Information

Stephen Crystal, PhD, MS
Rutgers University–New Brunswick
Comparative Effectiveness of State Psychotropic Oversight Systems for Children in Foster Care

Key Dates

April 2015
December 2020

Study Registration Information


Has Results
Award Type
Health Conditions Health Conditions These are the broad terms we use to categorize our funded research studies; specific diseases or conditions are included within the appropriate larger category. Note: not all of our funded projects focus on a single disease or condition; some touch on multiple diseases or conditions, research methods, or broader health system interventions. Such projects won’t be listed by a primary disease/condition and so won’t appear if you use this filter tool to find them. View Glossary
Populations Populations PCORI is interested in research that seeks to better understand how different clinical and health system options work for different people. These populations are frequently studied in our portfolio or identified as being of interest by our stakeholders. View Glossary
Intervention Strategy Intervention Strategies PCORI funds comparative clinical effectiveness research (CER) studies that compare two or more options or approaches to health care, or that compare different ways of delivering or receiving care. View Glossary
State State The state where the project originates, or where the primary institution or organization is located. View Glossary
Last updated: December 5, 2022