Research conducted by PolicyLab at The Children’s Hospital of Philadelphia laid the groundwork for new statewide initiatives that aim to reduce the use of psychotropic medications among Pennsylvania children in the foster care system who are enrolled in Medicaid.
At a press conference Tuesday, Feb. 23, announcing the changes, David Rubin, MD, MSCE, director of PolicyLab and a CHOP pediatrician, recalled the case of a bright 5-year-old boy who had experienced abuse and neglect before entering the state’s foster care system. Several day care directors had dismissed him from their programs due to his disruptive behavior. By the time the boy’s foster mother introduced him to Dr. Rubin, the child already had been prescribed two different psychiatric medications, and his physician had recommended adding an antipsychotic medication with sedative qualities.
Psychotropic medications are a class of drugs that is used to treat or manage mental health symptoms or challenging behaviors. Antipsychotic medications, which are primarily used to manage psychosis in serious mental illnesses such as schizophrenia and bipolar disorder, fall under this category. Since they can have significant side effects, antipsychotics should be prescribed under careful consideration and subject to ongoing monitoring over time.
“These medications increasingly are being prescribed off-label to control behaviors of kids who are acting out,” Dr. Rubin said. “There are approved indications for those types of medications, but principally we’ve seen the growth over time in the use of medications like antipsychotics to control disruptive behaviors by in essence sedation.”
He worried about the potential risks and long-term consequences of these medications on the precocious 5-year-old. Ideally, a trauma-based care model and alternative nonpharmacological psychosocial interventions perhaps could have made a difference, he said. Yet those types of services often are difficult to access or coordinate and seem too complicated for families in crisis who are looking for a “magic bullet” solution.
Unfortunately, the boy’s story is all too common. PolicyLab research commissioned by the Pennsylvania Department of Human Services has shown that the use of psychotropic medications was three times higher among 6 to 18-year-olds in foster care than among youth in Medicaid overall. More than half of youth antipsychotic users in Medicaid had a diagnosis of attention-deficit/hyperactivity disorder. The majority of these youth did not have another diagnosis that clinically indicated the use of antipsychotics.
In response to PolicyLab’s research and analysis, DHS partnered with experts from CHOP, the American Academy of Pediatrics, and the Pennsylvania Psychiatric Society last year to start taking a serious look at psychotropic prescribing practices for children.
“This has truly been a team effort and a testament to what can happen when government throws open the doors and doesn’t huddle in a corner and try to do things by themselves but reaches out to the experts in the field to give us their guidance and input to hopefully turn around this issue,” said DHS Secretary Ted Dallas. He announced several steps his office will take to address this critical issue:
- Implement prior authorization and reauthorization of antipsychotic medications for all physical-health managed care organizations
- Disseminate best practice guidelines for primary care physicians and psychiatrists regarding comprehensive assessments of behavior and treatment interventions
- Deploy an electronic dashboard to help monitor the use of antipsychotics in children and adolescents and their associated physical and behavioral healthcare services
- Create a telephone hotline to assist medical clinicians when prescribing psychotropic medications for children
- Adopt a new training module that will be offered to child welfare caseworkers, and birth, kinship, and foster parents regarding the appropriate use of psychotropic medications.
“We think all of these things in combination will have a huge impact on the prescription of psychotropic drugs for children in Pennsylvania, and hopefully it may also be something that folks in other states may want to take a look at,” Dallas said. “While we’re very happy with the progress we’ve made, we are by no means satisfied. We know there is a lot more to do. Working with our partners at CHOP and PolicyLab, I have no doubt that we’re going to continue to make progress.”
Kathleen Noonan, JD, PolicyLab co-founder and CHOP's Associate Vice President of Board Relations, served as the co-chair of the psychotropic subcommittee of the DHS Committee on Foster Care and Health. In that role, she helped create recommendations for how the commonwealth could address this problem.
"At PolicyLab, we believe that producing academic literature is not sufficient. In order to have an impact, you have to do things," Noonan said. "An evidence to action mission means you have to get on the train and go to Harrisburg and D.C., and that's what we do."