A scientific report, soon to be published in the Journal of Child and Adolescent Psychopharmacology, includes strong words of caution for everyone involved in decisions that lead to medication of foster children with antipsychotic drugs.
The study of one state’s Medicaid data looked at records for low-income publicly insured youth who were 2 through 17 years old in 2006, including those in foster care. It is the first study to examine “the greatly expanded use of atypical antipsychotics in foster youth diagnosed as having ADHD with no other psychiatric condition.” Researchers confirmed disturbing patterns of atypical antipsychotic use to control behavioral conditions. They also found that foster children were more likely to be on these drugs much longer than other Medicaid-insured youth.
The authors warn: “antipsychotic use in youth for ADHD and other behavioral problems underscores the need for oversight . . . to assure that benefits outweigh the risks. Atypical antipsychotic use for off-label behavioral conditions such as ADHD now accounts for the majority of antipsychotic-treated youth with Medicaid coverage, raising short- and long-term safety concerns in the absence of sufficient efficacy data to justify potentially severe treatment-emergent adverse effects.” Such risks demand “laboratory monitoring to assure appropriate use of atypical antipsychotics” which, the authors note, “has been largely absent.”
- One-third of ADHD-diagnosed foster children aged 2 to 12 years old were administered atypical antipsychotics. The young age of these children is a particular concern, as is the frequency of this off-label practice.
- ADHD-diagnosed foster youth were prescribed antipsychotics three times more often than the other groups of low-income children
- One-half of children on antipsychotics were on the medication for 6 months or longer, but those in foster care were medicated longer (240 days median duration during a one-year period) than any other group of children, including those on SSI.
- ADHD-diagnosed foster children were administered antipsychotics more than 100 days longer than any other group of low-income children with the same diagnosis.
- More than 7% of youth on antipsychotics were administered two or more at the same time, “raising major safety and appropriateness concerns in the absence of efficacy or effectiveness data supporting the use of two or more antipsychotics . . . .”
Why these Findings are Alarming and a Call for Action:
- The FDA has approved atypical antipsychotics only for children diagnosed as having schizophrenia, bipolar disorder, or irritability associated with autism. None of the atypical antipsychotics is FDA-approved for “behavioral” disorders, yet Medicaid-insured youth labeled with diagnoses such as “conduct disorder” are by far the largest group of youth receiving antipsychotics.
- Atypical antipsychotics administered much more briefly than was typical for the foster children in the new study often have caused cardiac and metabolic abnormalities such as “significant weight gain, hypercholesterolemia, sharp increases in triglyceride levels, elevations in blood glucose, and insulin resistance . . . .” The longer a child is administered an antipsychotic, the greater the risk of adverse effects. Laboratory monitoring assures that when changes signal increased risk, the medication can be withdrawn gradually to prevent additional risk.
- Children on antipsychotics sometimes suffer dyskinetic movement disorders. These abnormal and involuntary movements are visible in the children’s faces and limbs. Normal movement usually is recovered if the antipsychotic drug is discontinued, but for some children the movement disorder is permanent. Educating parents and caregivers to monitor for the development of such movements is a priority.
- Adverse drug effects are more likely when children are given multiple psychotropic drugs or for longer periods of time, both of which are more common in the management of foster children.
- Antipsychotic drugs are being administered to Medicaid-insured children and youth largely without the precautionary monitoring necessary to detect common adverse effects such as cardiac and metabolic abnormalities.
Risks Can Be Reduced
To reduce inappropriate use, Maryland has expanded its peer review pre-authorization of antipsychotic drugs to all children younger than 18. Other states that use variations of this method include Illinois, Minnesota, and Ohio. A summary of the Maryland program with a hyperlink to a more detailed PowerPoint presentation is available here.
Does your state have a peer review pre-authorization program? Is your state considering such a program? Let us know with an e-mail to email@example.com.
 Burcu, M, Zito, J.M., Ibe, A., & Safer, D.J., Atypical antipsychotic use among Medicaid-insured children and adolescents: duration, safety, and monitoring implications. In press, 24 J. of Child & Adolesc. Psychopharm., 2014.