Balancing Risks and Benefits: Stakeholder Perspectives on Antipsychotic Medication Use for Youth in Foster Care

Background:

In 2012, federal mandates required state child welfare agencies to develop plans for oversight regarding the prescribing and monitoring of AP medications for youth in foster care, reflecting widespread concern about the rates at which these medications are used in this population. These guidelines were informed by a growing body of research indicating the numerous safety concerns that accompany prescriptions of AP meds. These concerns include same-class and cross-class polypharmacy, prescribing APs for very young children, side effects in youth, medication adherence, and the use of AP meds in lieu of psychosocial interventions.

This study examines the perceptions of risks as well as potential benefits associated with antipsychotic prescriptions for youth in foster care from key stakeholder perspectives.

Methods:

Semi-structured interviews and focus groups were completed with distinct stakeholder groups with lived experience in prescribing, being prescribed or overseeing prescriptions for antipsychotic medication.  This presentation describes findings from four stakeholder groups: clinicians (n= 32), foster caregivers (n = 20), child welfare caseworkers (n = 24) and foster youth alumni (n= 8 focus groups). Participants were recruited from four states through snowball sampling methods through state agencies and advocacy organizations.  Trained investigators collected data using semi-structured interviews and Deliberative Discussion focus groups.

Data analysis included descriptive and bivariate summaries of stakeholders’ demographic and background information. Four trained qualitative analysts conducted the analysis using Dedoose software. Emergent and a priori coding structure was employed. Thematic findings will be presented with illustrative quotes. Interrater reliability for analysts ranged from .74 to .89 across all stakeholder groups.

Results:

All stakeholder groups identified both risks and benefits of using AP medications.  Consistent with extant research, major risks discussed included were polypharmacy and side effects (e.g., weight gain; drowsiness; general dulling of functioning). Polypharmacy was a treatment pattern of particular concern and was often perceived as intertwined with discontinuous care for youth in foster care. However, despite the perceived risks, all stakeholders recognized and cited instances where such treatments could be beneficial. AP medications were endorsed for emergencies, behaviors related to severe mental illness, and trauma. Of note, the benefits discussed also were qualified with comments such as “only with youth buy-in” or “not without therapeutic services too.”  

 Stakeholders identified various processes by which risks to AP medication use in foster youth can be mitigated. Promoting youth comprehension of medications, side effects, treatment plans, and adherence were strategies to reduce risk. Stakeholders also mentioned youth engagement, encouraging conservative prescription practices, and ensuring appropriate informed consent.

Implications:

Results highlight the complexity of the multi-decision-maker process of prescribing AP medications for youth in foster care, and the need for individualized decision-making. Improving the process for youths’ informed consent and comprehension could help balance the risk-benefit ratio in treatment with AP medications.  In instances when antipsychotic medications are utilized, stakeholders endorsed a proactive and ongoing approach to managing treatment, with advance consideration of strategies for dealing with possible complications rather than ad hoc reaction to complications after they arise.