Behavioral Health Services Utilization before and after Antipsychotic Drug Initiation Among Children in Foster Care

Background. Youth in foster care are at high risk for severe behavioral health care challenges that left untreated, could lead to health and economic disparities later in life. Despite a greater need for behavioral care, there are persistent gaps between the child welfare and health service systems. These gaps create barriers to receiving evidence-based mental health services (e.g., therapeutic foster care and multisystemic therapy.) This gap is often filled by pharmacotherapy, a less service-intensive form of care. Although antipsychotic drugs (ATPs) can be an effective complement to behavioral interventions, ATPs carry significant potential health risks. Youth in foster care are much more likely to be prescribed ATPs than youth not in out-of-home care, and these youth receive an inconsistent array of services. The extent of unmet need for behavioral therapies and interventions among foster youth prescribed ATPs is a highly understudied area. In this descriptive study, we examine services received before and after initiation of ATPs, and change in service utilization after initiation.

Methods. Using 2011-2018 Medicaid claims from a southeastern state, we identified a retrospective cohort of 6-18 year old foster care youth prescribed an ATP. Within a 6-month window of continuous Medicaid eligibility before and after initiation, we identified those youth who were provided the following services: psychiatric residential treatment facility (PRTF), psychiatric hospitalization, inpatient and outpatient psychiatric care, psychotherapy, Multisystemic Therapy (MST), Therapeutic Foster Care (TFC), group residential care, and in-home or wraparound services. We examined foster youth at large and foster youth excluding those who had a diagnosis indicated for ATPs (Tourette’s, Autism Spectrum Disorder, bipolar disorder, and psychosis.) In addition, we examined changes in care at the individual level after initiation.

Results. Among all foster care youth initiating ATPs, one percent or fewer of the youth received MST or TFC before or after ATP. Use of group residential care, in-home services, and PRTFs rose after initiation. Psychiatric hospitalization was much lower after prescribing (from 19.8% down to 13.2%.) Rates of inpatient and outpatient psychiatric care were slightly lower after prescribing. Similar patterns were observed for youth without an ATP indication, although the rate of psychiatric hospitalization was much higher before initiation (38.1%.) Looking at individual-level changes in service utilization, youth without an indicated diagnosis had a 25% reduction in the rate of psychiatric hospitalization; in the at large population, the reduction was 13.2%. Some youth obtained services after prescribing that they did not obtain before, most notably psychotherapy.

Conclusions/Implications. These changes in service utilization represent trends that are both concerning (few children are served by TFC before or after ATP initiation) and promising (reduction in psychiatric hospitalization). Increasing the availability of services like MST and TFC is critical, which recent federal policy changes may help facilitate. Further research is needed that utilizes quasi-experimental methods to disentangle the causal effects of ATP on service utilization, which will be challenging because of confounding by indication—that youth who get ATPs are likely to be different from youth who do not, e.g., on intensity of needs.