Psychotropic Medication Patterns for American Indian Children in Foster Care

Abstract

Objective:

This study assesses the effects of race, age, sex, and time spent in foster care on rates of psychotropic medication use for children in foster care in 2012.

Methods:

Using existing electronic records through county Social Service and Minnesota Medical Assistance databases, 626 children were identified using the inclusion criteria of having been in foster care for at least 30 days during 2012 in St. Louis County, Minnesota. All prescriptions for dispensed psychotropic medications were identified into the following classes: antidepressants, attention-deficit/hyperactivity disorder (ADHD) medications, antipsychotics, alpha-agonists, and other (including anticonvulsants/mood stabilizers, lithium, benzodiazepines, and sedative hypnotics).

Results:

Overall, 26% of children were dispensed at least one psychotropic medication during the year with the percentage of children on medication for each race as follows: American Indian (AI) 23.3%, European American (EA) 29.2%, and African American (AA) 18.3%. AI children were significantly less likely to be dispensed any psychotropic medication and ADHD medication. EA children, males, and older children received psychotropic medications from significantly more classes than AI or AA children, females, and younger children. Males were significantly more likely to be dispensed alpha-agonists, antipsychotics, and ADHD medications. Increased time since placement into foster care was also significantly associated with increased dispensing rates of antidepressants, ADHD medication, and multiple medication classes.

Conclusions:

The results of this study show that non-EA children, in particular AI children, were dispensed psychotropics both overall and across different medication classes less often compared to other racial groups. While the reasons for this difference are not known, future studies are needed to address whether mental health needs of all children in foster care are being appropriately addressed, accounting for need and patient preference.

Introduction

It is well documented that nationwide, and in states such as Minnesota, American Indian (AI) and African American (AA) children are overrepresented in foster care (Minnesota Department of Human Services 2014, 2016). In 2012, there were 397,153 children in foster care in the United States (U.S. Department of Health and Human Services 2012) and 9149 placements of children in foster care in Minnesota (Minnesota Department of Human Services 2013). In Minnesota in 2012, AI and AA children were 14.3 and 4.3 times more likely to be placed in foster care compared to European American (EA) children (U.S. Department of Health and Human Services 2012).

Children in foster care are 2.7–4.5 times more likely to be prescribed psychotropic medications (Kutz 2011), which are much higher than rates for children in the general population (dosReis et al. 2011). This tendency toward medicating children in foster care at considerably higher rates has become concerning to clinicians and many state and federal regulatory agencies (AACAP 2012; Alavi and Calleja 2012). Recently, this has been attributed, in part, to higher incidence of mental health diagnoses for children in foster care (Steele and Buchi 2008; Zito et al. 2008; Littrell 2012). One study estimated that as many as 96% of children in foster care have identified mental health or behavioral issues (Simms et al. 2000); however, other studies indicate more modest estimates ranging from 40% to 57% (Horowitz et al. 2000; dosReis et al. 2001).

Research has examined additional characteristics of prescribing patterns in children. For example, multiple studies indicate increased use of psychotropic medications for older children and males (Zima et al. 1999; Raghavan et al. 2005). Other studies also show a child's race/ethnicity to be a significant predictor of use of psychotropic medication from specific classes. Specifically, EA children are more likely to receive concomitant medications compared to children from other racial backgrounds (Zito et al. 2008).

To the best of our knowledge, only one published study has examined psychotropic medication prescriptions for AI children in foster care (Ferguson et al. 2006). In this study, EA children received psychotropic medication at significantly higher rates than AI children, but there was no significant difference across drug categories for children from either racial group. In general, AI children continue to be significantly underrepresented in research, especially in studies on use of psychotropic medication. The current study is an extension and replication of the previous study by Ferguson et al. (2006).

The primary objective of this study was to determine the rate of psychotropic medication dispensing patterns for children in foster care, particularly for AI children during 1 year. Secondary objectives included the likelihood of children in foster care receiving psychotropic medications based on their age, race, sex, and time in care, as well as overall psychotropic prescription dispensing patterns, classes of psychotropic medications, and the frequency of concomitant medication use during the study year.

Methods

Data for this cross-sectional study were obtained from existing medical assistance records for children in foster care during 2012. St. Louis County, Minnesota includes a large rural area, as well as the medium size city of Duluth. The Minnesota Department of Human Services, the University of Minnesota Institutional Review Board (IRB), and the St. Louis County Attorney's Office (Public Health and Human Services Division) granted approval for the study. The information in the dataset was deidentified and part of existing records; therefore, informed consent was not deemed necessary by the IRB.

Selection of participant and psychotropic medication records

A search in 2013 of the Social Services computerized records identified 626 children residing in foster care in 2012 for at least 30 days. Children were excluded if they were diagnosed as developmentally disabled, were over 17 years of age, and/or if they lived in residential placement or shelter facilities. Confidentiality was maintained by removing all identifying information.

Demographic information from the social services records included age, sex, race, and length of time in foster care through the last month of 2012. Length of time in care includes time in care before 2012. AI children who identified as more than one race were included in the AI category because children eligible for tribal membership are protected by, and receive other services through, the Indian Child Welfare Act (NICWA 2016). Other than AI cases, multiracial children were excluded from this study.

Participant prescription records from payment data from the 2012 Minnesota Medical Assistance (Medicaid) database were obtained for all dispensed psychotropic medications. Using the National Drug Code, medications were categorized according to the American Hospital Formulary Service (2010), as well as review by a clinical pharmacologist (J.T.B.). Classes include antidepressants, attention-deficit/hyperactivity disorder (ADHD) medications [including stimulants (e.g., methylphenidate and dextroamphetamine/amphetamine) and the nonstimulant atomoxetine], antipsychotics, alpha-agonists, and other (including anticonvulsants/mood stabilizers, lithium, benzodiazepines, and sedative hypnotics).

Statistical analyses

All analyses, including descriptive statistics, Chi-square tests, logistic regression, and Poisson regression, were performed using SAS software. Independent variables included a child's race, age group (0–4, 5–9, 10–14, and 15–17 years old), sex, and total length of time in foster care. Chi-square tests were used to determine race/ethnicity effects with sex, age group, and time in foster care (0–6, 7–12, 13–24, 25–60, and >60 months). Logistic regression was conducted to assess statistical significance of factors influencing whether children were dispensed any psychotropic medications and specific classes of psychotropic medications. Poisson regression was used to examine the relationships between the number of dispensed medication classes at any time during 2012 and demographic characteristics. With only two children 0–4 years old, including this almost absent age group when fitting models assessing effects of race, gender, and time in foster care is problematic. The 0–4 years age group was removed in the final analyses, but the group was retained in summary tables (Tables 1 and 2). Time in foster care was modeled as linear for up to 20 months and constant thereafter, a piecewise linear effect with zero slope at the upper end. This model was determined by inspecting smoothing models and comparing likelihoods using different age cutoffs for the leveling off time.

Table 1.

Summary of Participant Demographics

	Total (N = 626)		EA (N = 332)		AI (N = 223)		AA (N = 71)
	n	%	n	%	n	%	n	%	p
Sex									0.252
Female	283	45.2	160	48.2	95	42.6	28	39.4
Male	343	54.8	172	51.8	128	57.4	43	60.6
Age									0.613
0–4 years old	249	39.8	126	38.0	91	40.8	32	45.0
5–9 years old	144	23.0	75	22.6	52	23.3	17	23.9
10–14 years old	122	19.5	71	21.4	37	16.6	14	19.7
15–17 years old	111	17.7	60	18.1	43	19.3	8	11.3
Time in foster care									0.001
0–6 months	185	29.6	92	27.7	70	31.4	23	32.4
7–12 months	155	24.8	88	26.5	44	19.7	23	32.4
13–24 months	128	20.5	73	22.0	41	18.4	14	19.7
25–60 months	104	16.6	60	18.1	34	15.3	10	14.1
>60 months	54	8.6	19	5.7	34	15.3	1	1.4

Number and percentages of children by sex, age, and time in foster care for total sample and each racial group.

AA, African American; AI, American Indian; EA, European American.

Table 2.

Number and Percentages of Dispensed Psychotropic Medication by Race/Ethnicity and Medication Class

	Total (N = 626)		EA (N = 332)		AI (N = 223)		AA (N = 71)
Medication classes	n	%	n	%	n	%	n	%	p
On any medication	162	25.9	97	29.2	52	23.3	13	18.3	0.090
Antidepressant	87	13.9	49	14.8	30	13.5	8	11.3	0.721
ADHD	89	14.2	60	18.1	24	10.8	5	7.0	0.010
Alpha-agonists	45	7.2	28	8.4	15	6.7	2	2.8	0.237
Antipsychotic	32	5.1	22	6.6	8	3.6	2	2.8	0.182
Other	30	4.8	20	6.0	9	4.0	1	1.4	0.205

AA, African American; ADHD, attention-deficit/hyperactivity disorder; AI, American Indian; EA, European American.

Results

Participant demographics

This study included 626 children, 332 EAs (53%), 223 AIs (36%), and 71 AAs (11%). There were 283 females (45%) and 343 males (55%) in the sample. The percentage of males was higher overall and for each racial category, with the largest discrepancy occurring in AA (61%) and the least in EA (52%). It was found that race and time in foster care were significantly associated (χ² = 25.9, df = 8, p = 0.001). The percentage of AI children having been in FC for 60 or more months was notably greater than for EA or AA. Neither sex nor age was significantly associated with how long the children had been in FC. Table 1 summarizes sample sizes and percentages of children by sex, age group, time in foster care for total sample, and each racial group.

Analysis of foster children on medication

A total of 162 (26%) children were dispensed at least one psychotropic medication during the year. Of these, there were 97 (60%) EAs, 52 (32%) AIs, and 13 (8%) AAs. The percentage of children on medication for each race was as follows: EA 29.2% (97/332), AI 23.3% (52/223), and AA 18.3% (13/71). There were 65 (40%) females and 97 (60%) males who were dispensed psychotropic medications in 2012. It was found that the dispensed ADHD medication had a significant race/ethnicity effect (χ² = 9.2, df = 2, p = 0.01). Race and medication classes are summarized in Table 2.

Age was found to be significantly associated with dispensing any medication in 2012 and each of the medication classes. Children of 5–9 years old were one-sixth less likely to be on any medication compared to the reference group [odds ratio (OR) = 0.17, df = 1, p < 0.001]. Although there were no significant differences between 10–14 years old and 15–17 years old in dispensing medications, the age effects of children of 5–9 years old were significant: antidepressants (OR = 0.13, df = 1, p < 0.001), ADHD (OR = 0.34, df = 1, p = 0.002), and antipsychotics (OR = 0.2, df = 1, p = 0.008).

Race was found to be significantly associated with medication dispensing for ADHD (χ² = 8.8, df = 2, p = 0.012). AI children were less likely to be dispensed ADHD medications (OR = 0.47, df = 1, p = 0.01) and any medication (OR = 0.61, df = 1, p = 0.05).

Males were significantly more likely to be dispensed the following medication classes: ADHD medications (OR = 2.49, df = 1, p = 0.001), alpha-agonists (OR = 2.39, df = 1, p < 0.015), and antipsychotics (OR = 4.04, df = 1, p = 0.003).

Each year in care of up to 20 months resulted in an about twofold increase in the chance of a child being dispensed any medication (OR = 2.11, df = 1, p < 0.001), antidepressant (OR = 1.79, df = 1, p = 0.02), and ADHD medications (OR = 2.23, df = 1, p = 0.02). ORs, confidence intervals (CIs), and p-values are summarized in Table 3. Figure 1 illustrates a comparison of dispensed ADHD medication by race and sex adjusted for age and time in foster care.

FIG. 1.

A comparison of ADHD medication dispensation by race and sex, adjusted for age and time in foster care. ADHD, attention-deficit/hyperactivity disorder; F, female; M, male.

Table 3.

Odds Ratios, Confidence Intervals, and p-Values for Dispensed Medication by a Child's Age, Race, Sex, and Time in Foster Care (N = 377)

	Any medication			Antidepressant			ADHD			Alpha-agonists			Antipsychotic
Variables	OR	CI	p	OR	CI	p	OR	CI	p	OR	CI	p	OR	CI	p
Age (Ref: 15–17 years old)			<0.001			<0.001			0.001			0.099			0.029
5–9 years old	0.17	0.10–0.31	<0.001	0.13	0.06–0.27	<0.001	0.34	0.17–0.67	0.002	0.71	0.29–1.71	0.441	0.20	0.06–0.66	0.008
10–14 years old	0.64	0.37–1.12	0.117	0.59	0.33–1.04	0.066	1.10	0.60–1.99	0.766	1.63	0.75–3.54	0.213	0.66	0.28–1.53	0.331
Race (Ref: EA)			0.111			0.949			0.012			0.331			0.178
AA	0.63	0.29–1.36	0.240	1.06	0.43–2.59	0.906	0.37	0.13–1.03	0.056	0.34	0.08–1.50	0.152	0.49	0.11–2.30	0.368
AI	0.61	0.37–1.00	0.050	0.93	0.53–1.62	0.791	0.47	0.26–0.83	0.010	0.80	0.40–1.59	0.531	0.46	0.19–1.10	0.081
Male	1.39	0.88–2.20	0.158	0.80	0.48–1.34	0.395	2.49	1.45–4.29	0.001	2.39	1.18–4.83	0.015	4.04	1.58–10.29	0.003
Time in foster care	2.11	1.40–3.17	<0.001	1.79	1.10–2.91	0.020	2.23	1.34–3.70	0.002	1.30	0.71–2.38	0.388	1.93	0.86–4.29	0.109

AA, African American; ADHD, attention-deficit/hyperactivity disorder; AI, American Indian; CI, confidence interval; EA, European American; OR, odds ratio.

Analysis of multiple medication patterns

Poisson regression analysis of numbers of medication classes by race showed that EA children received psychotropic medications from significantly more classes than children of other races as follows: AA [incidence rate ratio (IRR) = 0.6, df = 1, p = 0.038, EA-AA = 0.52] and AI (IRR = 0.71, df = 1, p = 0.011, EA-AI = 0.34). Comparison between AA and AI showed no significant differences. Males received psychotropics from significantly more medication classes compared to females (IRR = 1.44, df = 1, p = 0.004), as did older children (IRR for 5–9 years old = 0.32, df = 1, p < 0.001). Time in foster care also had significant impact on the number of medication classes dispensed to children (IRR = 1.46, df = 1, p = 0.001). IRRs, CIs, and significance levels are summarized in Table 4.

Table 4.

Poisson Regression of Multiple Medication Classes by a Child's Race, Sex, Age, and Months in Foster Care (N = 337)

Variables	IRRs	CI	p
Age (Ref: 15–17 years old)			<0.001
5–9 years old	0.32	0.22–0.46	<0.001
10–14 years old	0.89	0.69–1.16	0.395
Race (Ref: EA)			0.008
AA	0.60	0.37–0.97	0.038
AI	0.71	0.55–0.93	0.011
Male	1.44	1.12–1.84	0.004
Time in foster care	1.46	1.16–1.85	0.001

AA, African American; AI, American Indian; CI, confidence interval; IRRs, incidence rate ratios; EA, European American.

Discussion

Medication and age

Overall, a child's age, sex, race, and time in foster care were associated with many aspects of dispensed psychotropic medications. Consistent with our results related to age and likelihood for psychotropic medication use, one study examining Medicaid records in Ohio found that older children in foster care were significantly more likely to be prescribed psychotropic medications across a 5-year span compared to younger children (Fontanella et al. 2014). Our results are in agreement that older children were significantly more likely to be dispensed medications from specific classes, including ADHD medications and antidepressants. This is also consistent with previous studies examining age and medication types. In a multistate study of Medicaid enrolled children in foster care, medication use increased across antidepressants, antipsychotics, and stimulants (Rubin et al. 2012). Another study found a significant increase in the use of antipsychotics and stimulants among children in foster care as they increased in age (dosReis et al. 2014). Notably, this study only examined very young children (ages 6 years and younger), whereas our study included a broader range of age.

Medication and race

Our cross-sectional results show that there were several significant differences in psychotropic medication use among children in different racial groups: AI children were significantly less likely to be dispensed any psychotropic medications, ADHD medications, and multiple medications during the year compared to EA children. AA children were also significantly less likely to be dispensed multiple medications during the year. These findings are supported in the literature as children of EA origin are more likely to be prescribed psychotropic medication compared to children from other racial groups, including AA (Leslie et al. 2003; Zito et al. 2008; Warner et al. 2014) and AI children (Ferguson et al. 2006). Previous studies have shown that antipsychotic and multiple medications are often used in situations when children in foster care engage in severe behavior (e.g., aggression), which could be one of the reasons for the racial differences in use of antipsychotic medications from these classes (Brenner et al. 2014). Studies have shown that AI families have higher incidences of neglect and fewer incidences of child abuse as reasons for placement than EA families, and AI children in care have lower rates of delinquent behavior (Donald et al., 2003).

Although AI children are overrepresented in foster care (Ferguson et al. 2006; Carter 2011; Scannapieco and Iannone 2012), use of psychotropic medications with these children continues to be understudied. Despite the lack of empirical studies examining use of psychotropic medications among AI children, some studies postulate why AI children were less likely to be prescribed ADHD medications. For example, an analysis of Medicaid expenditures revealed that AI children were less likely to use behavioral health services compared to EA children (Pires et al. 2013). Moreover, a study of traditional AI healers suggested that fear and distrust of Western Medicine prevented AI people from seeking help after experiencing mental health symptoms (Bassett et al. 2012). This is potentially due to historical trauma and oppression of indigenous peoples in North America (Gone 2007). It is also possible that psychotropic medication usage may conflict with traditional health practices within AI culture (Bassett et al. 2012).

Medication and sex

Comparable to other studies, our study had significant results for males in four areas: the medication classes of: alpha-agonists, antipsychotics, ADHD, and being dispensed more than one class of medication during the year. Sex effects are consistent with prior studies (Zima et al. 1999; Ferguson et al. 2006; Zito et al. 2008). While ADHD and antipsychotic prescription rates could be influenced by higher diagnosis rates of ADHD, schizophrenia, and bipolar in males (Matone et al. 2012), we were unable to discern this, as diagnoses were not available in our sample.

Medication and time in foster care

Our results showed that children in foster care for a longer period of time were more likely to be on medication overall and for ADHD, antidepressants, and multiple medication classes. To our knowledge, previous research has not examined the length of time in foster care as a factor in psychotropic medication use. However, certain parallels can be drawn from related research on diagnoses and children in foster care. For example, the American Academy of Pediatrics (2015) indicated that children in foster care were thrice more likely to be diagnosed with ADHD compared to children not in care. However, because the data did not contain diagnoses, it is unknown whether dispensed stimulants were for ADHD or unrelated behavioral symptoms (e.g., aggression). In a broader context, this finding is of importance in understanding that mental health and behavioral issues are identified and treated more often for children in foster care compared to children in the general population (Oswald et al. 2010). Therefore, it would make sense that children in foster care for a greater period of time would have more opportunities to be identified as having a mental health diagnosis or behaviors that might be treatable with psychotropic medication.

Strengths and limitations

One of the strengths of this study is having data for AI children in foster care, which is only the second time psychotropic medication patterns for this patient population have been examined (Ferguson et al. 2006). The study also reports on how time in foster care may impact psychotropic medication use, which has not been examined in previous research.

The cross-sectional sample reported in this study is a limitation versus a longitudinal study. Since the data were limited to one largely rural geographic area, results are limited in generalizability to other populations and areas. It is also important to note that while our study is unique in comparing the dispensing patterns of five psychotropic medication classes across three different racial categories, it also means that the numbers within each category of analysis were small in some instances. Therefore, while there are several significant results, they may lack the statistical power that a larger sample, and the subgroups within, would have.

Finally, while our results showed differences in psychotropic medication use across several child demographics, decisions about treatment for mental health issues or behaviors are complex and go beyond the limited information to which we had access. We did not include diagnoses in our dataset and it was not possible to tell if individuals entered the foster care system on psychotropic medication or if medications were started after entering foster care. Our study is also limited in that we do not know at a case level how prescription treatment decisions were made, including on which behaviors or diagnoses prescribers were relying, and the extent to which other service providers or family members were consulted. We do not have information about other treatment modalities used or offered along with psychotropic medications. Psychotropic medications may have been offered or recommended to children and families, but alternative treatments were possibly chosen based on family preference. It is also not possible to know whether a child's placement played a role in access to mental health or medical services, as services and practitioners in St. Louis County are not distributed evenly geographically.

Conclusions

The results of this study show that AI children are dispensed fewer psychotropic medications compared to other racial groups, implying either lower prevalence of psychiatric diagnoses or possibly undertreatment or over medication of EA children. For children in foster care, research continues to document increased prescribing of psychotropic medications, including antipsychotics (Zito et al. 2008; Vanderwerker et al. 2014). Antipsychotic medications are used frequently for children with externalizing behaviors and are used at higher rates with children in foster care (Vanderwerker et al. 2014; Zito et al. 2013; Brenner et al. 2014; Kreider et al. 2014). This study shows that psychotropic medications, in general, and antipsychotics, in particular, are used long term with children in foster care, similar to what has been found in other research (Zito et al. 2013). This is concerning due to increased risk for developing type 2 diabetes (Bobo et al. 2013), weight gain and metabolic abnormalities (Calarge et al. 2009; Correll et al. 2009), and potentially deleterious endocrine and other side effects with chronic exposure to drugs from this category (Jerrell and McIntyre 2008).

These findings and the results from the current study argue for the examination of alternative or adjunct treatment to the use of psychotropic medications to treat mental health for children in foster care. One such approach may be therapeutic/treatment foster care (TFC) (Robst et al. 2011; Brenner et al. 2014; McMillen et al. 2015). Although the exact nature of the TFC interventions varies, the evidence from existing studies suggests that this approach is effective for older children with psychiatric diagnoses, children in the correction system in foster care, and those in group homes (Brenner et al. 2014). Future research should focus on defining which TFC model is most beneficial with or without adjunct medication therapy. Key to evaluating this approach will be careful monitoring of psychotropic medications, especially usage of antipsychotics and multiple medications that potentially have serious, long-term side effects (Jerrell and McIntyre 2008).

Additional research should examine the rationale for the use of psychotropic medications for alleviating symptoms, including whether there is evidence that severe or aggressive behavior is improved by specific medications. Research should also explore whether potential benefits of using psychotropic medications in this manner outweigh the long-term risks of exposure. As our data show, EA children in care are dispensed psychotropic medication at higher rates than children of other racial groups. Therefore, studies should investigate how mental health needs of children in foster care are being differentially addressed across race/ethnicity.

Clinical Significance

While there were several significant results, the main finding was that non-EA children, in particular AI children, were dispensed psychotropic medications across different classes less often compared to children in other racial groups. Because psychotropic medication use among AI children in foster care has been understudied, these results highlight the importance of continued research on how the mental health needs of AI children in foster care are being addressed.

Footnotes

Acknowledgments

Dr. Donald Ferguson passed away in September due to complications from cancer. He spent his career diligently advocating for the physical and mental wellbeing of children in foster case in his capacity as psychologist for St. Louis County Public Health and Human Services' Children and Family Services Division. Dr. Ferguson made contributions to this manuscript right up to the week he died.

The authors would like to thank the St. Louis County Public Health and Human Services Department for its support in conducting this research, especially Ann Busche and Holly Church, and the Minnesota Department of Human Services for assistance in procuring the data.

Disclosures

No competing financial interests exist.

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