Use of Psychotropic Medications and Evidence-Based Treatments for Disruptive Behavior in Foster Care (WITHDRAWN)

Background. As in the general population, use of evidence-based treatments (EBTs) to address foster children’s disruptive behavior problems is inconsistent. While use of EBTs is low, a dramatic increase in use of psychotropic medications has occurred in the past two decades. A particular concern is the increased use of antipsychotics, which are now prescribed 5-6 times more often in foster care than in the general population. These medications reduce aggression but have negative metabolic effects and possible long-term developmental consequences. This raises critical questions about the treatment of disruptive behavior in foster care.  Are children prescribed medications in lieu of effective therapy services? This study focused on a sample of children at high risk for disruptive behavior to identify (1) the extent that therapy services provided to foster children with disruptive behavior reflect evidence-based practices and (2) factors predicting psychotropic and antipsychotic use.

Methods. Foster parents (N = 144) caring for children age 8-14 (M=11.67) with a history of two or more moves in foster care were randomly selected across a Midwestern state.  Participants completed a 90-minute telephone interview (86% response rate) that included standardized measures of behavior problems and functioning, mental health diagnoses, medication use and therapeutic services content. Bivariate analyses assessed the extent services reflected EBPs.  Predictors of psychotropic and antipsychotic medication use (e.g., severity of high risk behaviors, risk to others, placement moves, hospitalizations, demographics) were analyzed using multinomial regression.  

Results. Children were 61% African American and 62% male. Over half (56.3%) of the sample had ADHD or disruptive behavior diagnoses; 53% of these children were taking a psychotropic medication other than an antipsychotic and 25.9% were taking an antipsychotic (primarily Risperidone). The majority (66%) received therapy. Multiple indicators suggest that only 30-34% of therapeutic services provided to children with disruptive behavior were consistent with an EBT. Children taking a psychotropic or antipsychotic medication were no more or less likely to be receiving an EBT. Multivariate results indicate that predictors of use of a psychotropic (other than antipsychotic) included ADHD diagnosis and higher levels of high risk behaviors (e.g., aggression, outbursts). Predictors of antipsychotic use included high risk behaviors as well as male gender, older age, and prior hospitalizations (ps < .05 for all). History of psychosis or mania did not account for these relationships.

Implications. Decisions about mental health treatments for foster children are made by professionals rather than parents who may be more wary of using treatments with significant side effects. Findings from this study indicate that children with a history of moves who have disruptive behavior, particularly boys, are often prescribed antipsychotic medications while receiving psychosocial treatments that do not reflect empirically-based practice guidelines. Hospitalizations appear to play a role in antipsychotic use, suggesting that either prior incidents leading to hospitalization or prescribing patterns at hospitals might contribute to greater use. An increased focus on the content of therapeutic services and case review prior to prescribing antipsychotics is essential to optimize benefits of treatment and reduce risk of harms.