Psychotropic Medication Prescription Patternsifs.sc.edu/MPR/Reports/PsychtropicMedsReport_REVJan3113.pdf · Psychotropic Medication Prescription Patterns ... ADHD was the most common

Psychotropic Medication Prescription Patterns Among Children in South Carolina Medicaid

Ana Lòpez‐De Fede, PhD

Medha Vyavaharkar, PhD, MPH, MD, DNB

Jessica D. Bellinger, PhD, MPH

Developed by the

Institute for Families in Society

Division of Policy and Research on Medicaid and Medicare

University of South Carolina

Under contract to the SC Department of Health and Human Services

Updated January 2013 Any copies dated prior to January 2013 should be replaced with this version of the report which reflects

formatting and related corrections made to any version dated December 2012 or earlier.

Suggested citation: Lòpez‐De Fede A, Vyavaharkar M, & Bellinger JD. (2013). Psychotropic medication prescription patterns among children in South

Carolina Medicaid 2012. Columbia, SC: University of South Carolina, Institute for Families in Society.

Stock image sources: dreamstime.com and stockfreeimages.com

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EXECUTIVE SUMMARY

Psychotropic medication use has increased markedly in children

and adolescents with psychiatric disorders. Children in foster care

are particularly vulnerable due to biological, psychological, and

social risk factors that may lead to emotional and/or behavioral

problems. Previous studies have illustrated many of the adverse

effects of inappropriate utilization of psychotropic medications in

children, such as poorer health status, higher obesity and diabetes

prevalence, and minimal control of behavioral problems. This

report seeks to expand the growing body of literature on

psychotropic medication use in children enrolled in South Carolina

Medicaid program, particularly for children in the foster care

system. Evidence‐based recommendations for providing quality

psychiatric care to children enrolled in Medicaid are presented.

Information for the report was drawn from South Carolina Medicaid claims housed at the Institute for

Families in Society (University of South Carolina). Children with at least one psychotropic medication

prescription in calendar year (CY) 2011 were included in the de‐identified data for a retrospective

analysis from January 1, 2009, through December 31, 2011. The status of the children in the study was

classified as adoption, ISCEDC (Interagency System of Care for Emotionally Disturbed Children), MCC

(Medically Complex Children), regular foster care, and non‐foster care. Race/ethnicity was defined as

non‐Hispanic White (hereafter “White”), non‐Hispanic African American/Black (hereafter “African

American”), and “Other” which included all other children including those identified as Hispanic, Asian

and Pacific Islander (API), American Indian and Alaska Native (AI/AN), and multiracial. Descriptive

statistics and comparisons are provided for the following groups: 1) children in regular foster care vs.

children in non‐foster care, 2) children in ISCEDC vs. children in regular foster care, and 3) children in

adoption category vs. children in regular foster care.

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Key findings of the report include:

General Profile

Children enrolled in SC Medicaid who received at least one psychotropic medication prescription

in CY 2011 were predominantly males (60%) and had an average age of 12 years.

Nearly a third of the sample lived in rural areas and less than a fifth lived in areas with high

social deprivation.

Based on the clinical risk group (CRG) system classification, all children in MCC category were

classified under severe‐to‐catastrophic CRG followed by nearly 90% of ISCEDC children, 63% of

regular foster care children, 59% of adopted children, and 54% of non‐foster care children.

Children in ISCEDC category were significantly more likely, but children in non‐foster (53.81%)

and adoption (58.84%) categories were significantly less likely to be categorized under severe‐

to‐catastrophic CRG compared to children regular foster care category (63.01%).

Nearly one in five children (17%) did not have a listed psychiatric diagnosis in their claims data.

ADHD was the most common psychiatric diagnosis irrespective of the child’s foster care status.

Children in ISCEDC category (99.35%) were significantly more likely, but children in non‐foster

(82.37%) and adoption (89.92%) categories were significantly less likely to have listed psychiatric

diagnoses compared to their regular foster care peers (93.34%).

Prescription Patterns

Receipt of Psychotropic Prescriptions

The top three psychotropic drug classes prescribed included ADHD medications (73.18%),

antidepressants (23.72%), and anticonvulsants (14.49%). Barbiturate sedatives and mood

stabilizers were the least prescribed medications.

More than three quarters of the children received medications from a single psychotropic drug

class (mono‐class treatment).

Irrespective of the child’s foster care status, the top two psychotropic drug class combinations

were ADHD medications and antidepressants followed by ADHD medications and antipsychotics.

Children in regular foster care category (31.86%) were significantly more likely than those in

non‐foster category (22.66%) and significantly less likely than those in ISCEDC category (63.10%)

to receive multi‐class (two or more drug classes) psychotropic treatment.

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Receipt of Antipsychotic Prescriptions

Males were significantly more likely to receive antipsychotic prescriptions compared to females

across all status categories.

All children in foster care category and nearly all children in ISCEDC category who received

antipsychotics had listed psychiatric diagnoses. However, nearly 4% of children in adoption and

5% of children in non‐foster category did not have any listed psychiatric diagnoses despite

receiving antipsychotic prescriptions.

The majority of children who received antipsychotics also received medications from one or

more other psychotropic drug classes (87.83%). Of the total children on antipsychotics, nearly

44% received medications from three or more drug classes.

When compared by status, children in ISCEDC category were significantly more likely than

children in regular foster category to receive medications from three or more drug classes.

Among children who received antipsychotic medications, those with second‐generation

antipsychotic prescriptions were more likely to be adherent than those with first‐generation

antipsychotic prescriptions.

Receipt of Psychiatric Services

Of the total sample, 36.26% received psychiatric services as adjunct therapy to psychotropic

medication(s).

The proportion of children receiving psychiatric services was highest among children in ISCEDC

category and lowest among those in MCC category.

Children in regular foster care category (71%) were significantly more likely than children in non‐

foster category (34.44%) and those in adoption category (46.18%), but significantly less likely

than children in ISCEDC category (91.67%) to receive psychiatric services.

Among those who received antipsychotic prescriptions, overall more than two thirds of children

(68.09%) received psychiatric services. Children in regular foster care were significantly more

likely to receive psychiatric services compared to those in non‐foster and adoption categories.

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Recommendations and Future Steps

The study findings suggest that there are several opportunities to improve the oversight and

management of psychotropic medications prescribed to children in Medicaid proactively and in a holistic

manner. Based on the study findings, this report offers key recommendations using the patient‐

centered medical home (PCMH) framework, which is designed to orient strategies to refine and improve

the organization of health care delivery. These recommendations include:

Psychiatric diagnosis must be documented by applying specific diagnostic criteria using screening

and evaluation protocols for children, youth, and adolescents enrolled in SC Medicaid irrespective of

their foster care status.

A comprehensive mental health treatment plan that includes psychiatric services as alternative or

adjunct to pharmacological treatment and provisions of second opinion by a qualified psychiatrist

when appropriate should be developed by a psychiatrist in consultation with the primary care

provider.

Regular monitoring of psychotropic medication prescription patterns/use should be conducted on a

semi‐annual basis.

Information exchange and care coordination among providers, patients, and caregivers should be

considered critical elements of overall patient management plan.

Training and continuing education programs for providers should include mandatory mental health

components and updates related to changes in clinical practice guidelines related to psychotropic

medication use among children and adolescents.

Establish a psychotropic medication oversight advisory committee consisting of a wide range of

stakeholders to oversee psychotropic medication prescriptions for children and adolescents enrolled

in Medicaid with annual reports to state agencies.

Future studies should continue research on trends in psychotropic medication prescription patterns and

undesirable health impacts of these medications, particularly among high risk children who receive

multiple psychotropic medications concurrently.

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Table of Contents

EXECUTIVE SUMMARY ............................................................................................................................... i

GLOSSARY ................................................................................................................................................ vii

ORGANIZATION OF THE REPORT ............................................................................................................. ix

CHAPTER 1: INTRODUCTION ................................................................................................................... 10

Background ......................................................................................................................................... 10

Purpose of the Report ......................................................................................................................... 11

Research Questions ............................................................................................................................ 11

CHAPTER 2: PSYCHOTROPIC PRESCRIPTION CLAIMS ............................................................................. 13

Section I: Characteristics of Children Receiving Prescriptions of Psychotropic Medications ............. 15

General Profile ................................................................................................................................ 15

Clinical Risk Groups by Child Status ................................................................................................ 16

Psychotropic Prescription Patterns ................................................................................................ 16

Psychiatric Diagnoses ..................................................................................................................... 24

Receipt of Psychiatric Services ........................................................................................................ 25

Section II: Comparisons Between Regular Foster Care and Non‐Foster Care Children ...................... 26




Section III: Comparisons Between Children in ISCEDC and Regular Foster Care Categories .............. 31




Section IV: Comparisons Between Children in Adoption and Regular Foster Care Categories .......... 35




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CHAPTER 3: ANTIPSYCHOTIC PRESCRIPTION CLAIMS ............................................................................ 39

Profile of Children Receiving Prescriptions of Antipsychotic Medications ......................................... 39

Patterns of Antipsychotic Drug Prescriptions by Child Status, Gender, and Age ............................... 41

Psychiatric Diagnoses .......................................................................................................................... 42

Receipt of Psychiatric Services ............................................................................................................ 43

Antipsychotic Medication Adherence ................................................................................................. 44

Presence of Selected Non‐Psychiatric Diagnoses that Need Close Monitoring ................................. 47

CHAPTER 4: DISCUSSION ......................................................................................................................... 48

Summary of the Findings .................................................................................................................... 48

Previously Recommended Protocol Standards and Psychotropic Drug Safety .................................. 51

Recommendations .............................................................................................................................. 55

Implications of Findings and Suggestions for Future Research .......................................................... 59

Study Limitations and Strengths ......................................................................................................... 60

Conclusions ......................................................................................................................................... 60

TECHNICAL NOTES ................................................................................................................................... 61

ACKNOWLEDGEMENTS ........................................................................................................................... 63

REFERENCES ............................................................................................................................................. 64

APPENDIX ................................................................................................................................................ 67

APPENDIX A: Findings by Psychotropic Drug Classes .......................................................................... 68

APPENDIX B. Psychotropic Medications – List of Brand Names ......................................................... 83

APPENDIX C. Psychiatric Diagnoses for Children in Study .................................................................. 87

APPENDIX D. Description of CPT Codes .............................................................................................. 88

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GLOSSARY Below is a glossary of terms and acronyms associated with psychotropic prescriptions used extensively in this report. See the technical notes for detailed information on study variables of interest.

Term/Acronym Definition

Adherence The extent to which patients take medications as prescribed by their health care providers. The term “adherence” is generally preferred by providers due to the passive patient behavior referenced with the “compliance” term. Both terms are imperfect descriptions of medication‐taking behavior and not actual observation of consumption of prescribed medications.

Adoption Adoption is the practice in which an adult assumes the role of parent for a child who is not the adult's biological offspring in a formal legal arrangement. Adoption is a subcategory of foster care in this report. Children and youth with adoptive parents are no longer in foster care services. However, some adoptive parents receive financial assistance to help sustain the adoption given the special needs and/or circumstances of the children adopted. Adoption subsidies are funded through SC Medicaid, thus these children are continued as part of the foster care database for administrative purposes. Although, no longer in foster care, these children were considered a sub‐category of foster care for this study.

Antipsychotics These are psychotropic drugs used to treat psychotic disorders. They are usually classified into two categories: first generation (typical) antipsychotics and second generation (atypical) antipsychotics.

Compliance The extent to which patients take medications as prescribed by their health care providers. The term “adherence” is generally preferred by providers due to the passive patient behavior referenced with the “compliance” term. Both terms are imperfect descriptions of medication‐taking behavior and not actual observation of consumption of prescribed medications.

CRG Clinical Risk Groups (CRGs) are a clinical model in which each individual is assigned to a single mutually exclusive risk group which relates the historical clinical and demographic characteristics of the individual to the amount and type of health care resources that individual will consume in the future. The categories are ranked in order of severity.

CPT Code Current Procedural Terminology (CPT) codes describe medical, surgical, and diagnostic services offered to the patients. The list of CPT codes is published by the American Medical Association.

Foster Care System in which a minor who has been made a ward is placed in an institution, group home, or private home of a state certified caregiver. The placement of the child is usually arranged through the government or a social service agency. Several subcategories of foster care are in this report: adoption, ISCEDC, MCC, and regular foster care.

viii

Term/Acronym Definition

ICD‐9‐CM ICD‐9‐CM (International Classification of Disease, 9th edition, Clinical Modification) is a standardized classification of disease, injuries, and causes of death, by etiology and anatomic localization and codified into a 6‐digit number, which allows clinicians, statisticians, politicians, health planners and others to speak a common language, both in the United States and internationally.

ISCEDC Children with emotional disturbances who meet the eligibility criteria for Interagency System of Care for Emotionally Disturbed Children in South Carolina. A foster care subcategory in this report.

MCC Foster care designation for Medically Complex Children (MCC). Subcategory of foster care children in this report.

MPR

Medication Possession Ratio is a medication utilization metric that measures patient’s adherence or compliance and is defined as the sum of a medication’s days of supply divided by the total number of days in a time interval.

Mono‐class Therapy

Receipt of medication from a single psychotropic class (see Psychotropic Drug Class).

Multi‐class Therapy

Receipt of medications from two or more psychotropic classes.

PSADI The Palmetto Social Deprivation Index (PSADI) is a scale of indicators of social deprivation developed for South Carolina based on selected Census criteria. Similar to the Townsend Index for Social Deprivation.

PDC Proportion of Days Covered (PDC) is a medication utilization metric, which measures each day with a supply of the medication(s) of interest over a specific time period.

Psychiatric Diagnoses

Clinical diagnosis of mental health condition based on reported ICD‐9 diagnostic codes.

Psychiatric Services

Adjunct services (such as psychotherapy, counseling, or family therapy) offered to persons with psychiatric conditions.

Psychotropic Drug Class

Psychiatric medications used to treat mental disorders. Sometimes called psychotherapeutic medications. Eight classes are referenced in this report: attention deficit/hyperactivity disorder (ADHD) medications, antianxiety medications, anticonvulsants, antidepressants, antipsychotics, barbiturate sedatives, mood stabilizers, and non‐barbiturate sedatives.

RUCA Rural‐Urban Commuting Area Codes are a new Census tract‐based classification scheme that utilizes the standard Bureau of Census Urbanized Area and Urban Cluster definitions in combination with work commuting information to characterize all of the nation's Census tracts regarding their rural and urban status and relationships.

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ORGANIZATION OF THE REPORT

This report is organized into four chapters. Chapter 1 is an overview of background information about

the use of psychotropic medications among children, the rationale for and the purpose of the study,

and research questions. Chapter 2 focuses on South Carolina Medicaid children who received

prescriptions for psychotropic medication(s) in calendar year 2011. In addition to describing their

demographic characteristics, it also describes their health status based on CRG classification, reported

psychiatric diagnosis, the patterns of psychotropic prescriptions, and receipt of psychiatric services, if

any. This chapter includes four sections. The first section describes overall characteristics of children

enrolled in SC Medicaid who received at least one prescription of psychotropic medication in calendar

year (CY) 2011.

The remaining three sections describe comparisons between 1) regular foster care children and non‐

foster care children, 2) children under ISCEDC category and regular foster care children, and 3) children

under adoption category and regular foster care children. Chapter 3 focuses exclusively on children

who received antipsychotic medication prescriptions. This chapter also includes similar comparisons

(regular foster vs. non‐foster, ISCEDC vs. regular foster, and adoption vs. regular foster) as in Chapter 2.

In addition to demographic characteristics, CRG status, psychiatric diagnosis, and adjunct psychiatric

services, this chapter also describes compliance to antipsychotic medications. Chapter 4 offers

discussion on the study findings and policy recommendations. Additionally, it lists potential limitations

of the study. A detailed description of methods (study sample, variables of interest and their

definitions, statistical analyses, etc.) is outlined in the technical notes. Detailed tables of the study

findings are included in the appendices.

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CHAPTER 1: INTRODUCTION Background

Over the past two decades, the use of psychotropic medications for children and adolescents with

psychiatric disorders has increased considerably, primarily due to better understanding of childhood

psychiatric disorders and evidence base supporting the use of such medications.1, 2 Although there is

substantial evidence supporting use of a single psychotropic medication, not enough evidence is available

regarding use of psychotropic medication combinations. These combinations are often used to treat

complex comorbid conditions, enhance outcome for treatment refractory conditions, or manage side

effects of the primary medications.1 Further, medical providers often use psychotropic medications “off‐

label” or inconsistent with product labeling to suit the child’s needs.1 In many instances, the prescriber is a

non‐psychiatric physician.2, 3

Concomitant use of psychotropic medications or poly‐pharmacy is common among children, including

those in foster care, despite lack of adequate research on safety and efficacy of multi‐class psychotropic

regimens.3 National trends in psychotropic poly‐pharmacy among children and adolescents indicated that

there was a significant increase in the proportion of children who received two or more psychotropic drugs

from different drug classes in an outpatient setting between 1996 and 2007 and that a majority of

psychotropic visits were to non‐psychiatric physicians.4 Researchers from Florida examined prevalence of

poly‐pharmacy of antipsychotic medications among children and adolescents enrolled in Florida’s Medicaid

fee‐for‐service program using Medicaid claims data and found that 7% of children and 8% of adolescents

received poly‐pharmacy.5

As previously stated, off–label use of psychotropic medications is also common among youth. For example,

a retrospective cohort study using data from children and adolescents enrolled in Tennessee’s managed

care program for Medicaid and uninsured found that the proportion of children using antipsychotic

medications nearly doubled between 1996 and 2001 and that there was a significant increase in the use of

antipsychotic medications for attention‐deficit‐hyperactivity disorder (ADHD), conduct disorder, and

affective disorder.6 Analysis from a nationally representative sample of children revealed that overall

frequency of antipsychotic prescription increased from 8.6 per 1,000 US children in 1995‐96 to 39.4 per

1,000 US children in 2001‐02 and that more than half of the prescriptions were for behavioral or affective

disorders.2

Many children in foster care have biological, psychological, and social risk factors that lead to emotional

and/or behavioral problems.7, 8 Foster care children with health care needs often experience fragmented

medical and psychiatric care as a result of multiple placements and lack of resources for assessing and

treating them.2 These children are often prescribed psychotropic medications at higher rates compared to

their non‐foster peers enrolled in Medicaid and those with private insurance.9, 10 In an examination of

antipsychotic medication use among Medicaid‐enrolled foster care children in 48 states between 2002 and

2007, rates were stable or decreased in only 3 states while increases ranged from 6.4% to 71.9% in the

remaining states.11 The rate of second generation antipsychotic use in in South Carolina increased 41.3%

11

between 2002 and 2007.11 Further, poly‐pharmacy and “off‐label” use of psychotropic medication are

common in foster care children. In a study comparing concomitant antipsychotic use among Medicaid‐

enrolled youth in foster care with disabled or low‐income Medicaid youth, researchers found that youths in

foster care were more likely to receive antipsychotics concomitantly and for longer duration of time

despite lack of supporting evidence.12 In general, it is recommended that pharmacotherapy should be

combined with another evidence‐based treatment such as psychotherapy, family skills training, or behavior

management among children with a mental disorder.13

Although the use of psychotropic medications has been shown to effectively treat mental health

conditions, there are concerns about efficacy of poly‐pharmacy and its potential long term impact on

health, particularly among children. Limited information is available regarding prescription patterns of

psychotropic medications and the use of adjunct therapy among children enrolled in South Carolina

Medicaid. Whether foster care children have been disproportionately prescribed psychotropic medications

compared to non‐foster children in Medicaid, particularly in the absence of adjunct therapy, remains to be

determined. If so, current guidelines and recommendations for initiating and monitoring psychotropic

prescriptions will need to be revised to prevent non‐indicated and inappropriate prescriptions of

psychotropic medications.

Purpose of the Report

The purpose of this study was to describe psychotropic medication prescription patterns among South

Carolina Medicaid‐enrolled children who have received psychotropic medication(s) in calendar year 2011

with special attention given to those children receiving foster care services. Additionally, the study

compared these prescription patterns by child status, age group, gender, race, and residence in areas with

social deprivation. Further, the analyses focused on children who received prescription of antipsychotic

medication(s) since there is a growing concern over increasing trend of using antipsychotic medications

among children.

Research Questions

The following research questions were considered.

1. What is the profile of children enrolled under SC Medicaid who received at least one psychotropic prescription in CY 2011?

2. Among children enrolled under SC Medicaid who received psychotropic medications in CY 2011, what proportion of children in each group (non‐foster, adoption, ISCEDC, MCC, and regular foster care) received medications from the following drug classes: ADHD medications, antianxiety medications, anticonvulsants, antidepressants, antipsychotics, barbiturate sedatives, non‐barbiturate sedatives, and mood stabilizers?

3. What are the clinical risk group categories of children receiving psychotropic medication(s)?

4. What psychiatric diagnoses are assigned to children receiving psychotropic medications?

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5. What proportion of children in each group received multi‐class treatment (defined as receipt of psychotropic medications from two or more drug classes)?

6. What proportion of children in each group received additional psychiatric services as adjunct to the psychotropic medications?

7. Are there any group differences in socio‐demographic characteristics and receipts of psychotropic medication classes, psychiatric diagnoses, and psychiatric services by child status?

8. What proportion of children in each group who received antipsychotic medications have associated ICD‐9 diagnoses related to hyperglycemia, diabetes, weight gain, metabolic syndrome, pancreatitis, neurological/movement disorders, and cardiovascular complications?

13

Section I describes general profile of all children in the study sample;

Section II describes comparisons between regular foster care children

(not including those in adoption, ISCEDC, and MCC categories) and

non‐foster care children;

Section III describes comparisons between children in ISCEDC category

and regular foster care category; and

Section IV describes comparisons between children in adoption

category and regular foster care category.

CHAPTER 2: PSYCHOTROPIC PRESCRIPTION CLAIMS

As mentioned earlier, psychotropic medication use has increased markedly in children and adolescents;

however, there is still a lack of consensus on appropriate use for certain classes of drugs. In this chapter,

the profile of children enrolled in South Carolina Medicaid with at least one psychotropic medication

prescription in the CY 2011 is presented with information about their clinical status, demographic

characteristics, and use of psychiatric services.

Although, children under adoption, ISCEDC, and MCC categories are often grouped together with regular

foster care children under the foster care category, in our opinion, each of these subcategories has unique

features and should not be considered as a single group. We acknowledge that children once adopted

cannot be considered as foster care children since now they have legal parents. In that sense, they should

not be considered as a part of foster care children. Additionally, children in ISCEDC category have

documented needs of mental health services and are emotionally unstable. Their mental health service

utilization patterns including prescriptions of psychotropic medications and psychiatric services may be

higher compared to other children in foster care category. Higher mental health needs and mental health

service utilization among children under the ISCEDC category may influence results if they are considered

together with other foster care children. Therefore, we examined psychotropic prescription patterns and

mental health service utilization among these children based on their foster care status. In addition to the

descriptive statistics, we conducted chi‐square tests to compare children in different status categories. It

should be noted that given a very small sample size in MCC category (n=50), it was not included in further

analysis. This chapter includes four sections.

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Table 2.1 Characteristics of SC Medicaid Children Who Received at Least One Psychotropic Medication Prescription in CY 2011

Characteristic Total (n=62,859)

n % Sex

Male 38,888 61.87 Female 23,971 38.13

Age in years (Mean=11.85, SD=.02)

< 1 95 .15 1‐4 1,844 2.93 5‐9 18,801 29.91 10‐14 23,554 37.47 15‐17 11,216 17.84 18‐21 7,349 11.69

Race

White 33,174 52.78 African American 19,821 31.53 Other 9,864 15.69

Status

Non‐foster care 58,657 93.32 Foster care 4,202 6.68 Adoption† 2,252 3.58 ISCEDC† 924 1.47 MCC† 50 0.08 Regular foster† 976 1.55

Clinical risk group Healthy/moderate 28,476 45.30 Severe/catastrophic 34,383 54.70

Rurality‡ Urban 42,301 67.30 Large rural 13,807 21.97

Small rural 4,339 6.90 Isolated rural 2,383 3.79

PSADI‡ Low‐moderate deprivation 51,635 82.14 High rural deprivation 6177 9.83 High urban deprivation 5,018 7.98

Recorded psychiatric diagnosis 52,194 83.03

Receipt of psychiatric services 22,795 36.26

Note: † Adoption, ISCEDC, MCC, and Regular foster are subcategories of foster care. ‡ Columns may not total 100% due to rounding and missing values.

15

Section I: Characteristics of Children Receiving Prescriptions of Psychotropic Medications

General Profile

Table 2.1 describes the profile of SC Medicaid children who received at least one psychotropic prescription

in 2011. Highlights of the table are indicated below.

Demographic characteristics:

Males made up more than 60% of the total sample. The average age of

children in the sample was approximately 12 years with approximately 3%

of the children younger than 5 years of age. The largest proportion was in

the age group of 10‐14 years (37.47%) followed by age groups 5‐9 years

(29.91%) and 15‐17 years (17.84%). Slightly more than half of the sample

was White (52.78%). Approximately a third of SC Medicaid children

receiving psychotropic medications lived in rural areas (32.66%). When

examined by social deprivation indicator, overall 17.81% of the sample

lived in high deprivation areas.

Foster care status:

Children not in foster care were the overwhelming majority of Medicaid

enrollees in the sample (93.32%). Foster care status included four

categories, regular foster care, ISCEDC, MCC, and adoption. Out of 4,202

foster care children, the majority were classified under adoption category

(53.59%) followed by regular foster care (23.23%) and ISCEDC (21.99%).

Very few Medicaid enrollees in foster care were classified as medically

complex children (1.19%).

Clinical characteristics:

The majority of SC Medicaid children who received psychotropic

prescriptions in CY 2011 were categorized under severe to catastrophic

clinical risk group (CRG) categories (54.7%). Overall, nearly 83% of children

who received psychotropic medication prescriptions also had a reported

psychiatric diagnosis. Only about 36% of children received psychiatric

services in addition to the pharmacologic treatment.

16

58.84

89.94100

63.0153.81

0

20

40

60

80

100

Adoption(n=2,252)

ISCEDC(n=924)

MCC (n=50) Regular foster(n=976)

Non‐foster(n=58,657)

% Children With Severe‐to‐Catastrophic CRG

Clinical Risk Groups by Child Status

The clinical risk group (CRG) system classifies individuals into mutually exclusive categories and assigns each

person with a chronic health condition to a severity level based on enrollment, claims, or other encounter

level data. In the total sample,

4,546 children (7.23%) were

classified as healthy (CRG 1).

When considered by status,

as expected all children who

were classified as MCC had

severe‐to‐catastrophic CRG

(Figure 2.1) followed by

children with emotional

disturbances (89.94%). The

lowest proportion of children

classified as having severe‐to‐

catastrophic CRG was found

among non‐foster children

(53.81%).

Psychotropic Prescription Patterns

Eight classes of psychotropic medications are included in the profile of children enrolled in South Carolina

Medicaid. The psychotropic medication classes are ADHD medications, antianxiety medications,

anticonvulsants, antidepressants, antipsychotics, barbiturate sedatives, mood stabilizers, and non‐

barbiturate sedatives. All psychotropic medication use in children and adolescents require careful

monitoring by clinicians; however, the potential health complications associated with antipsychotic

medications in children are particularly grave. As such, Chapter 3 deals exclusively with children who

received antipsychotic prescriptions.

Table 2.2 describes the psychotropic prescription patterns among the study sample. The top three

psychotropic drug classes prescribed included ADHD medications (73.18%) followed by antidepressants

(23.72%) and anticonvulsants (14.49%). Barbiturate sedatives and mood stabilizers were the least

prescribed psychotropic medications during the study period. More than three quarters of children (76.3%)

received psychotropic medications from only one drug class (Mono‐class treatment).

Figure 2.1: CRG by Child Status

17

Table 2.2 Proportion of SC Medicaid Children Receiving Psychotropic Treatment by Drug Class and Type of Treatment (n=62,859)

Drug Class Total Mono‐Class

Treatment Multi‐Class Treatment

n % n % n %

All classes 62,859 100.00 47,958 76.30 14,894 23.7

ADHD medications 46,000 73.18 34,969 55.64 11,031 17.54

Antianxiety medications

4,190 6.67 2,098 3.34 2,092 3.33

Anticonvulsants 9,107 14.49 3,835 6.10 5,272 8.39

Antidepressants 14,909 23.72 5,439 8.65 9,470 15.07

Antipsychotics 7,221 11.49 879 1.40 6,342 10.09

Barbiturate sedatives 249 .40 102 .16 147 .23

Mood stabilizers 302 .48 12 .02 290 .46

Non‐barbiturate sedatives

1,423 2.26 624 .99 799 1.27

Among those who received multi‐class treatment (n=14,894), the top five combinations of psychotropic

drug classes included the following:

When examined by the CRG status (Table 2.3), the proportion of children categorized as severe‐to‐

catastrophic CRG was highest among those who received mood stabilizers (99.34%) followed by those who

received antipsychotics (92.62%). Children receiving ADHD medications had the lowest proportion of being

classified in the severe‐catastrophic category (50.67%). Significant differences were found in CRG

categories for all drug classes (p<.0001) except antianxiety drug class (p=.48).

1. ADHD medications and antidepressants (n=3,985, 26.76%),

2. ADHD medications and antipsychotics (n=2,090, 14.03%),

3. ADHD medications and anticonvulsants (n=1,122, 7.53%),

4. ADHD medications, antidepressants, and antipsychotics (n=1,120, 7.52%),

and

5. Anticonvulsants and antidepressants (n=776, 5.21%).

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Table 2.3 Receipt of Psychotropic Drug Class and Recipient’s CRG Classification

Psychotropic Drug Class Healthy‐to‐Moderate

(CRG 1‐4) % Severe‐to‐Catastrophic

(CRG 5‐9) % p value

ADHD (n=46,000) 49.33 50.67 <.0001

Antianxiety (n=4,190) 45.82 54.18 0.4823

Anticonvulsants (n=9,107) 14.11 85.89 <.0001

Antidepressants (n=14,909) 31.93 68.07 <.0001

Antipsychotics (n=7,221) 7.38 92.62 <.0001

Barbiturate sedatives (n=249) 10.44 89.56 <.0001

Mood stabilizers (n=302) 0.66 99.34 <.0001

Non Barbiturate sedatives (n=1,423) 39.56 60.44 <.0001

Note: Italicized percentages are based on cell sizes less than 30. Use caution in p value interpretation.

The remainder of this section describes each psychotropic drug class prescribed to the study sample. Please

note that MCC category is not included in the charts due to small cell sizes. Further, antipsychotic

medications are described in detail in Chapter 3.

ADHD Medications

Overall, 46,000 SC Medicaid

children (73.18% of the total

sample) received prescriptions of

ADHD medications in CY 2011.

Please refer to Appendix B2 for

ADHD medication list. Figure 2.2

indicates the proportion of children

receiving ADHD prescriptions by

sex and status. Males were more

likely to receive ADHD medications

compared to females irrespective

of their status. Among children

who received ADHD prescriptions,

the proportion of males was higher

among non‐foster category

(70.21%) compared to other

categories. Proportion of females

receiving ADHD medications in any

category was highest in the adoption category (38.98%).

69.6 70.2162.57 61.02 63.37

30.4 29.7937.43 38.98 36.63

0

20

40

60

80

100

Total(n=46,000)


Regular fostercare (n=756)

Adoption(n=1,911)

ISCEDC (n=677)

Proportion (%) of Children With ADHD Prescription by Sex and Status

Male Female

Figure 2.2. Receipt of ADHD medications among SC Medicaid children by sex and status.

19

Other findings among children receiving ADHD medication prescriptions (See Table A1 in Appendix A)

included:

The proportion of children receiving ADHD medications was highest among

children in the age group of 10‐14 years (43.33%) followed by the age group

5‐9 years (35.94%).

More than half of the children receiving ADHD medications were Whites.

Approximately half of the children were categorized as severe‐to‐

catastrophic CRG.

The majority lived in areas with low to moderate social deprivation

(82.36%).

The majority had a psychiatric diagnosis listed in the claims data (94.07%).

Less than 40% had received psychiatric services in addition to the

pharmacologic treatment.

Children in regular foster care were significantly more likely than children in

non‐foster care and adoption categories (all p<.0001), but less likely than

those in ISCEDC category (p<.001 and p<.0001 respectively) to have listed

psychiatric diagnoses and to receive psychiatric services.

Nearly one in four children (23.97%) received multi‐class treatment. Regular

foster care children were significantly more likely than non‐foster care

children, but less likely than ISCEDC children to receive multi‐class

treatment (both p<.0001).

20

Antidepressant Medications

Less than a quarter of the sample

received antidepressant

medications (n=14,909). Refer to

Appendix B3 for the list of

antidepressant medications. Figure

2.3 indicates distribution of children

receiving antidepressant

medications by sex and status. In

general, females were more likely

to receive antidepressants

compared to males except in

adoption category. However, these

differences were not statistically

significant.

Other highlights of the results (Table A2 in Appendix A) included:

Figure 2.3. Receipt of antidepressants among SC Medicaid children by sex and status.

45.93 45.65 46.00 51.32 47.6454.07 54.35 54.00 48.68 52.36

0

20

40

60

80

100

Total(n=14,909)

Non‐fostercare

(n=13,622)

Regularfoster care(n=300)

Adoption(n=532)

ISCEDC(n=445)

Proportion (%) of Children Receiving Antidepressants by Sex and Status

Male Female

The most common age groups for which antidepressants were prescribed, included 10‐14

years (31.44%) followed by 15‐17 years (29.66%) and 18‐21 years (26.48%).

More than two thirds (68.07%) were categorized as severe‐to‐catastrophic CRG.

The majority lived in areas with low‐moderate social deprivation (84.12%).

Nearly 83% had a listed psychiatric diagnosis.

Slightly more than half received psychiatric services in addition to pharmacologic treatment.

Children in regular foster care were significantly more likely than children in non‐foster care

category, but less likely than those in ISCEDC category to have listed psychiatric diagnoses

(both p<.0001).


and adoption categories, but less likely than those in ISCEDC category to receive psychiatric

services (all p<.0001).

More than 63% children who received antidepressants, received multi‐class treatment.

Regular foster care children were significantly more likely than non‐foster care children

(p<.001), but significantly less likely than ISCEDC (p<.001) and adoption (p=.01) children to

receive multi‐class treatment.

21

Anticonvulsant Medications

Of the SC Medicaid children who received psychotropic medication prescriptions in CY 2011, 9,107 children

(14.49%) received anticonvulsants (for the list of anticonvulsants, refer to Appendix B4). Of these 8,449

(92.77%) were non‐foster children. Irrespective of the status, males were more likely to receive

anticonvulsants compared to females (Figure 2.4). However, there were no statistically significant

differences in receipt of anticonvulsants by gender.

Other findings among children receiving anticonvulsants are reported in Table A4 in Appendix A. Some

highlights included:

The most common age groups receiving anticonvulsants included 10‐14 years (28.66%) followed by

15‐17 years (22.16%), and 18‐21 years (21.34%).

African Americans and other minorities made up more than half of the children receiving

anticonvulsants.

Nearly 86% of children receiving antianxiety medications were categorized as severe‐to‐

catastrophic CRG.

The majority lived in areas with low‐moderate social deprivation (81.39%).

Approximately 60% had a listed psychiatric diagnosis.

Approximately 36% received psychiatric services in addition to the pharmacologic treatment.


category, but less likely than those in ISCEDC category to have listed psychiatric diagnoses (both

p<.0001).

53.37 53.18 54.05 53.6658.67

46.63 46.82 45.95 46.3441.33

0

20

40

60

80

100

Total (n=9,107) Non‐foster(n=8,449)

Regular foster care(n=111)

Adoption (n=287) ISCEDC (n=225)

Proportion (%) of Children With Anticonvulsant Prescription by Sex and Status

Male Female

Figure 2.4. Receipt of anticonvulsants among SC Medicaid children by sex and status.

22


(p<.0001) and adoption (p=.002) categories, but less likely than those in ISCEDC category (p<.0001)

to receive psychiatric services.

Nearly 58% of children who received anticonvulsants received multi‐class treatment. Regular foster

care children were significantly more likely than non‐foster care children (p=.0002), but significantly

less likely than ISCEDC children (p<.0001) to receive multi‐class treatment.

Antianxiety Medications

Overall, 4,190 SC Medicaid

children (6.67% of the total

sample) received

prescriptions of antianxiety

medications in CY 2011.

Please refer to Appendix B5

for antianxiety medication

list. As shown in Figure 2.5,

females were more likely to

receive antianxiety

medications than their male

counterparts in non‐foster

care and adoption

categories.

Other findings among children receiving antianxiety prescriptions (See Table A4 in Appendix A) included:

The most common age groups receiving antianxiety medications were 18‐21 years (30.91%)

followed by 15‐17 years (23.96%).

Slightly more than half were Whites (51.60%) and were categorized as severe‐to‐catastrophic CRG

(54.18%).

The majority lived in areas with low to moderate social deprivation (80.19%).

Slightly more than half (51.31%) of the children receiving antianxiety medications had a psychiatric

diagnosis listed in the claims data.

Less than a quarter received psychiatric services in addition to the pharmacologic treatment.

Significantly more children in the “all foster care” category (please note that due to smaller sample

sizes in individual foster care categories, children in adoption, ISCEDC, MCC, and regular foster

were grouped together as an all foster care category) were significantly more likely to have listed

psychiatric diagnoses and receive psychiatric services compared to non‐foster children receiving

antianxiety medications (both p<.0001).

41.86 41.66

51.3543.04

54.8458.14 58.34

48.6556.96

45.16

0

20

40

60

80

100

Total(n=4,190)



Adoption(n=79)

ISCEDC (n=31)

Proportion (%) of Children With Antianxiety Prescription by Sex and Status

Male Female

Figure 2.5. Receipt of antianxiety medications among SC Medicaid children by sex and status.

23

Figure 2.6. Receipt of barbiturate sedatives among SC Medicaid children by sex and status.

48.19 48.23 47.8351.81 51.77 52.17

0

20

40

60

80

100

Total (n=249) Non‐foster care(n=226)

All foster care (n=23)

Proportion (%) of Children Receiving Barbiturate Sedatives by Sex and Status

Male Female

Figure 2.7. Receipt of mood stabilizers among SC Medicaid children by sex and status.

59.60 61.1152.00

40.40 38.8948.00

0

20

40

60

80

100

Total (n=302) Non‐foster care(n=252)


Proportion (%) of Children Receiving Mood Stabilizers by Sex and Status

Male Female

Nearly half of all children receiving antianxiety medications received multi‐class treatment.

Children in the all foster care category were significantly more likely to receive multi‐class

treatment compared to non‐foster children (p<.0001).

Barbiturate Sedative, Mood Stabilizer, and Non‐barbiturate Sedative Medications

Smaller proportions of children receiving

psychotropic medications received

barbiturate sedatives (n=249), mood

stabilizers (n=302), and non‐barbiturate

sedatives (n=1,423). Due to smaller sample

sizes in each status category by each of

these psychotropic drug classes, children

in regular foster care, adoption, ISCEDC,

and MCC categories were grouped

together in an all foster care category. The

distribution by gender and status (all

foster care vs. non‐foster) are reported for

each of these three classes.

Figure 2.6 indicates the proportion of

children receiving barbiturate sedatives by

sex and status. Overall, 249 children

(0.40% of the total sample) received

barbiturate sedatives. Of these children,

the majority were non‐foster children.

Other findings are reported in Table A5 in

Appendix A. No children in ISCEDC

category received barbiturate sedatives.

Reported p values are not reliable due to

small cell sizes.

Out of 302 children who received mood

stabilizers, the majority (83.44%) were

non‐foster children. Males were more

likely to receive mood stabilizers

compared to females among non‐foster

children (Figure 2.7). However, these

differences were not statistically

24

Figure 2.8. Receipt of non‐barbiturate sedatives among SC Medicaid children by sex and status.

43.29 42.9151.6156.71 57.09

48.39

0

20

40

60

80

100

Total (n=1,423) Non‐foster care(n=1,361)


Proportion (%) of Children Receiving Non‐barbiturate Sedatives by Sex and Status

Male Female

significant. Out of 50 foster care

children who received mood stabilizers,

26 were males. Estimates by gender

among foster care children are not

reliable due to smaller cell sizes.

Distribution of children receiving non‐

barbiturate sedatives by sex and status

is shown in Figure 2.8. The majority of

children receiving non‐barbiturate

sedatives were non‐foster children

(95.64%). There were no significant

differences in receipt of non‐

barbiturate sedatives by gender.


Eight categories of psychiatric diagnoses were examined using ICD‐9 codes (Please refer to the technical

notes for details). These included ADHD, adjustment disorders, anxiety disorders, disruptive behavior

disorders (conduct disorder and oppositional defiant disorder), mood disorders (bipolar disorder,

depressive disorder not classified elsewhere, and dysthymic disorder), pervasive developmental disorders

(PDD), psychotic disorders (schizophrenia, delusional disorders, & other non‐organic psychoses), and

substance abuse disorders (alcohol dependence syndrome, drug dependence, and non‐dependent drug

abuse). ADHD was the most common psychiatric diagnosis among children irrespective of the status. Table

2.4 indicates reported psychiatric diagnoses among the sample.

Table 2.4: Reported Psychiatric Diagnoses Among the Study Sample (n=62,859)

Psychiatric Diagnosis Category n %

ADHD 43,599 69.36

Adjustment disorders 7,058 11.23

Anxiety disorders 4,988 7.94

Disruptive behavior disorders 10,709 17.04

Mood disorders 9,987 15.89

Pervasive developmental disorders 3,169 5.04

Psychotic disorders 884 1.41

Substance abuse disorders 1,559 2.48

25

36.26 34.44

46.18

91.67

22.00

71.00

0

20

40

60

80

100

Total(n=62,859)


Adoption(n=2,252)

ISCEDC(n=924)

MCC (n=50) Regularfoster(n=976)

% Children Receiving Psychiatric Services

% Children receiving psychiatric services

Figure 2.9. Receipt of psychiatric services by status.


Figure 2.9 indicates proportion of children in each category who received psychiatric services in addition to

the pharmacologic treatment. Overall, slightly more than one third of children received psychiatric services.

The proportion of children receiving psychiatric services was highest among children under ISCEDC

category and lowest among those in MCC category. Approximately one third of non‐foster care children

received psychiatric services.

26

Section II: Comparisons Between Regular Foster Care and Non‐Foster Care Children

This section describes the psychotropic prescription patterns, reported psychiatric diagnoses, and receipt

of psychiatric services in addition to the pharmacologic treatment among regular foster care children and

non‐foster care children.

The characteristics of children in regular foster care and non‐foster care categories who received at least

one psychotropic prescription in CY 2011 are shown in Table 2.5.

Table 2.5. Characteristics of SC Medicaid Children in Regular Foster Care and Non‐Foster Care Categories Who Received at Least One Psychotropic Medication Prescription in CY2011

Characteristic Regular Foster Care (n=976) Non‐Foster (n=58,657)

p value n† % n %

Sex .0057 Male 564 57.79 36,434 62.11 Female 412 42.21 22,223 37.89 Age in years [Mean (SD)] [12.03 (0.15)] [11.80 (.02)] <.0001 < 1 ‐‐‐ ‐‐‐ 89 .15 1‐4 38 3.89 1,754 2.99 5‐9 274 28.07 17,831 30.40 10‐14 320 32.79 21,925 37.38 15‐17 200 20.49 10,181 17.36 18‐21 140 14.34 6,877 11.72 Race <.0001 White 488 50.00 31,198 53.19 African American 434 44.47 18,080 30.82 Other 54 5.53 9,379 15.99 Clinical risk group <.0001 Healthy/moderate 361 36.99 27,095 46.19 Severe/catastrophic 615 63.01 31,562 53.81 Rurality‡ <.0001 Urban 721 73.87 39,238 66.89 Large rural 173 17.73 13,090 22.32 Small rural 62 6.35 4,052 6.91 Isolated rural 18 1.84 2,252 3.84 PSADI‡ <.0001 Low‐moderate deprivation 660 67.62 48,414 82.54 High rural deprivation 109 11.17 5,737 9.78 High urban deprivation 205 21.00 4,481 7.64 Recorded psychiatric diagnosis 911 93.34 48,317 82.37 <.0001Receipt of psychiatric services 693 71.00 2,0204 34.44 <.0001

Note: ‐‐‐ Cell sizes less than 6 observations are suppressed. † Cell sizes less than 30 are italicized and are statistically unstable. ‡ Columns may not total 100% due to rounding and missing values.

27

The highlights of Table 2.5 include:

Although males made up the majority irrespective of the status, the proportion of males was

lower in the regular foster care category compared to that in the non‐foster category.

The proportion of Whites was slightly higher among non‐foster children (53.19%) compared to

the regular foster care category (50.0%).

Regular foster care children were significantly more likely to be categorized under severe‐to‐

catastrophic CRG compared to those from the non‐foster category (63.01% vs. 53.81%

respectively).

Regular foster care children were significantly more likely to have a listed psychiatric diagnosis

compared to non‐foster children (93.34% vs. 82.37% respectively).

Regular foster care children were significantly more likely to receive psychiatric services in

addition to the pharmacologic treatment compared to their non‐foster peers (71.0% vs. 34.44%

respectively).


The majority of children received a mono‐class treatment (receipt of psychotropic medication from a single

psychotropic drug class) irrespective of their status (68.14% of regular foster care and 77.34% of non‐foster

care children). Please note that seven children who received Provigil‐Nuvigil were not included in these

analyses due to extremely small sample size. Proportions of children in regular foster care and non‐foster

care categories receiving specific psychotropic drug class are shown in Table 2.6 below.

Table 2.6. Proportion of Regular Foster Care and Non‐Foster Care Children Receiving Specific Psychotropic Drug Classes in CY 2011

Psychotropic Drug Class Regular Foster Care (n=976) Non‐Foster (n=58,650)

p value n % n %

ADHD medications 756 77.46 42,652 72.71 .001

Antianxiety medications 37 3.79 4,037 6.88 .0001

Anticonvulsants 111 11.37 8,449 14.40 .0074

Antidepressants 300 30.74 13,622 23.22 <.0001

Antipsychotics 148 15.16 6,243 10.64 <.0001

Barbiturate sedatives 9 .92 226 .39 .0079

Mood stabilizers 6 .61 252 .43 .38

Non‐barbiturate sedatives 25 2.56 1,361 2.32 .62

Note: Italicized numbers indicate cell sizes less than 30 indicating caution while interpreting the results.

The top three drug combinations prescribed to children in regular foster care included ADHD medications

and antidepressants (n=104, 10.66%); ADHD medications and antipsychotics (n=46, 4.71%); and ADHD

medications, antidepressants, and antipsychotics (n=28, 2.87%). The top three drug combinations among

non‐foster children included ADHD medications and antidepressants (n=3,560, 6.07%); ADHD medications

and antipsychotics (n=1,794, 3.06%); and ADHD medications and anticonvulsants (n=1,039, 1.77%).

28

19.45 20.027.678.94 9.43 4.5

0

20

40

60

80

100

Total (n=10,665out of 62,859;

16.97%)

Non‐foster(n=10,335 out of58,650; 17.62%)

Regular foster(n=65 out of 976;

6.66%)

% Children on Psychotropic Treatment, but Without Listed Psychiatric Diagnosis

Mono‐class Treatment Multi‐class Treatment

Figure 2.10. Lack of listed psychiatric diagnosis by type of psychotropic treatment.

Among those who received multi‐class treatment, significantly more children in regular foster care received

medications from more than one psychotropic drug class compared to children in the non‐foster care

category (Table 2.7). The proportion of children in each category decreased as the number of psychotropic

drug classes increased. Significantly more foster care children received medications from three or more

psychotropic drug classes compared to their non‐foster care peers. However, when the cut‐off point was

raised to four drug classes or more, no statistical difference was found among children in the two

categories (Table 2.7).

Table 2.7. Multi‐Class Psychotropic Treatment Patterns Among Regular Foster Care and Non‐Foster Care

Children Who Received Psychotropic Prescriptions in CY 2011

Type of Multi‐Class Psychotropic Treatment

Regular Foster Care (n=976)

Non‐Foster (n=58,650) p value

n % n %

Two or more drug classes 311 31.86 13,293 22.66 <.0001

Three or more drug classes 87 8.91 3,781 6.45 .0019

Four or more drug classes 18 1.84 962 1.64 .62


Nearly 17% of children in our sample who

received psychotropic medications had not had

any psychiatric diagnosis listed in the claims data.

Overall, non‐foster children were significantly

more likely to have no reported psychiatric

diagnosis (17.62%) compared to regular foster

care children (6.66%). Approximately 20% of non‐

foster children receiving mono‐class treatment

did not have a listed psychiatric diagnosis

compared to 7.67% of regular foster care children

on mono‐class treatment (Figure 2.10). Among

children who received multi‐class treatment,

9.43% of non‐foster and 4.5% of regular foster care children did not have any listed psychiatric

diagnosis.

29


Approximately 93% of children in regular foster care and 82% of non‐foster children had listed psychiatric

diagnoses (Table 2.5). With an exception of pervasive developmental disorders (PDD) and psychotic

disorders, regular foster care children were significantly more likely to have specific psychiatric diagnoses

compared to non‐foster care children (Table 2.8). ADHD was the most common psychiatric diagnosis

among children irrespective of their foster care status. This was followed by adjustment disorders (44.47%),

disruptive behavior disorders (30.33%), and mood disorders (28.38%) among regular foster care children.

Among non‐foster care children, ADHD was followed by disruptive behavior disorders (15.86%), mood

disorders (14.74%), and adjustment disorders (9.62%). Table 2.8 indicates reported psychiatric diagnoses

among the study sample.

Table 2.8: Reported Psychiatric Diagnoses Among Regular Foster and Non‐Foster Children

Psychiatric Diagnosis Category

Regular Foster Care (n=976) Non‐Foster (n=58,657) p value*

n % n %

ADHD 744 76.23 40,262 68.64 <.0001*

Adjustment disorders

434 44.47 5,641 9.62 <.0001*

Anxiety disorders

94 9.63 4,587 7.82 .0369*

Disruptive behavior disorders

296 30.33 9,305 15.86 <.0001*

Mood disorders 277 28.38 8,644 14.74 <.0001*

Pervasive developmental disorders

24 2.46 2,944 5.02 .0003*

Psychotic disorders

16 1.64 774 1.32 .39

Substance abuse disorders

60 6.15 1,395 2.38 <.0001*

Note: Cell sizes less than 30 are italicized indicating caution while interpreting results. * Statistically significant differences between Regular Foster Care and Non‐Foster Care children.

30


Figure 2.11 displays the comparison of

regular foster care and non‐foster care

children who received psychiatric

services as adjunct to the

pharmacological treatment during the

study period. Receipt of psychiatric

services was determined by CPT codes

listed in the claims data (see technical

notes for specific CPT codes). There

was a significant difference in receipt

of psychiatric services among regular

foster care and non‐foster care

children with 71% of regular foster

care children receiving psychiatric

services compared to only about one

third (34.44%) of the non‐foster care

children (p<.0001).

Receipt of psychiatric services was also

examined to see if there were any

gender differences within each group.

As indicated in Figure 2.12, there were

no significant statistical differences in

receipt of psychiatric services among

regular foster care children by sex.

Nearly 73% of females and 70% of

males in the regular foster care

category received psychiatric services

during the study period. However,

among non‐foster children, males

(35.75%) were significantly more likely

to receive psychiatric services

compared to females (32.3%).

Figure 2.11. Receipt of psychiatric services as adjunct to pharmacological treatment; * p<.0001.

34.44*

71.00*65.56

29.00

0

20

40

60

80

100

Non‐foster care (n=58,657) Regular foster care (n=976)

% Children Who Received Psychiatric Services

Received psychiatric services Did not receive psychiatric services

35.75*

69.86

32.3*

72.57

0

20

40

60

80

100

Non‐foster care (n=58,657) Regular foster care (n=976)

% Children Who Received Psychiatric Services by Sex and Status

Male Female

Figure 2.12. Receipt of psychiatric services by sex and status;

* Statistically significant difference; p<.0001.

31

Section III: Comparisons Between Children in ISCEDC and Regular Foster Care Categories


of psychiatric services in addition to the pharmacologic treatment among children in ISCEDC category and

regular foster care category.

Table 2.9 indicates the socio‐demographic characteristics of children in regular foster care and ISCEDC

categories who received at least one psychotropic prescription in CY 2011.

Table 2.9: Characteristics of SC Medicaid Children in Regular Foster Care and ISCEDC Categories Who Received at Least One Psychotropic Medication Prescription in CY2011

Characteristic Regular Foster Care (n=976) ISCEDC (n=924)

p value n† % n %

Sex .81 Male 564 57.79 539 58.33 Female 412 42.21 385 41.67 Age in years [Mean (SD)] [12.03 (0.15)] [13.78 (0.11)] <.0001 < 1 ‐‐‐ ‐‐‐ ‐‐‐ ‐‐‐ 1‐4 38 3.89 38 3.89 5‐9 274 28.07 274 28.07 10‐14 320 32.79 320 32.79 15‐17 200 20.49 200 20.49 18‐21 140 14.34 140 14.34 Race <.0001 White 488 50.00 372 40.26 African American 434 44.47 373 40.37 Other 54 5.53 179 19.37 Clinical risk group <.0001 Healthy/moderate 361 36.99 93 10.06 Severe/catastrophic 615 63.01 831 89.94 Rurality‡ .41 Urban 721 73.87 710 76.84 Large rural 173 17.73 145 15.69 Small rural 62 6.35 54 5.84 Isolated rural 18 1.84 15 1.62 PSADI‡ .27 Low‐moderate deprivation 660 67.62 640 69.26 High rural deprivation 109 11.17 85 9.20 High urban deprivation 205 21.00 199 21.54 Recorded psychiatric diagnosis 911 93.34 918 99.35 <.0001

Receipt of psychiatric services 693 71.00 847 91.67 <.0001


32


There were no statistically significant differences among children in ISCEDC and regular foster

care categories by gender and area of residence (rural designation and social deprivation).

The proportion of minorities (African American and others) was significantly higher among

ISCEDC children (59.74%) compared to the regular foster care category (50.0%).

ISCEDC children were significantly more likely to be categorized under severe‐to‐catastrophic

CRG compared to those from the regular foster care category (89.94% vs. 63.01% respectively).

ISCEDC children were significantly more likely to have a listed psychiatric diagnosis compared to

regular foster care children (99.35% vs. 93.34% respectively).

ISCEDC children were significantly more likely to receive psychiatric services in addition to the

pharmacologic treatment compared to their regular foster care peers (91.67% vs. 71.0%

respectively).


The majority of children in regular foster care category received a mono‐class treatment (68.14%). In

contrast, the majority of children in the ISCEDC category received multi‐class treatment (63.10%). As

indicated in Table 2.10 below, among these children, the top three drug classes prescribed included

ADHD medications followed by antidepressants and antipsychotics irrespective of whether the child

belonged to regular foster care or ISCEDC category. Significantly more children in ISCEDC category

received prescriptions for antidepressants (48.16%), antipsychotics (47.51%), and anticonvulsants

(24.35%) compared to those in regular foster care category (30.74%, 15.16%, and 11.37% respectively).

Significantly more children from the regular foster care category received ADHD medications (77.46%)

compared to their ISCEDC peers (73.27%).

Table 2.10. Proportion of Regular Foster Care and ISCEDC Children Receiving Specific Psychotropic Drug Classes in CY 2011

Psychotropic Drug Class Regular Foster Care (n=976) ISCEDC (n=924)

p value n % n %

ADHD medications 756 77.46 677 73.27 .034

Antianxiety medications 37 3.79 31 3.35 .61

Anticonvulsants 111 11.37 225 24.35 <.0001Antidepressants 300 30.74 445 48.16 <.0001Antipsychotics 148 15.16 439 47.51 <.0001Barbiturate sedatives 9 .92 0 0 N/AMood stabilizers 6 .61 28 3.03 <.0001Non‐barbiturate sedatives 25 2.56 14 1.52 <.0001


33

The top three drug combinations among ISCEDC children included ADHD medications and

antidepressants (n=118, 12.77%); ADHD medications and antipsychotics (n=110, 11.90%); and ADHD

medications, antidepressants, and antipsychotics (n=89, 9.63%).

Among those who received multi‐class treatment, significantly more children in ISCEDC received

medications from more than one psychotropic drug class compared to children in the regular foster care

category (Table 2.11). The proportion of children in each category decreased as the number of

psychotropic drug classes increased. However, the differences in the proportions of children in each

group receiving medications from multiple psychotropic drug classes remained statistically significant

(Table 2.11).

Table 2.11. Multi‐Class Psychotropic Treatment Patterns Among Regular Foster Care and ISCEDC Children Who Received Psychotropic Prescriptions in CY 2011

Type of Multi‐class Psychotropic Treatment

Regular Foster Care (n=976) ISCEDC (n=924) p value

n % n %

Two or more drug classes 311 31.86 583 63.10 <.0001

Three or more drug classes 87 8.91 271 29.33 <.0001

Four or more drug classes 18 1.84 73 7.90 <.0001


Psychiatric Diagnoses Table 2.12 indicates reported psychiatric diagnoses among the children in regular foster care and ISCEDC

categories. With the exception of substance abuse disorders, ISCEDC children were significantly more

likely to have received specific psychiatric diagnosis compared to regular foster care children.

Table 2.12. Reported Psychiatric Diagnoses Among Regular Foster and ISCEDC Children

Psychiatric Diagnosis Category Regular Foster Care (n=976) ISCEDC (n=924)

p value* n % n %

ADHD 744 76.23 773 83.66 <.0001*Adjustment disorders 434 44.47 565 61.15 <.0001*Anxiety disorders 94 9.63 144 15.58 <.0001*Disruptive behavior disorders 296 30.33 647 70.02 <.0001*Mood disorders 277 28.38 638 69.05 <.0001*Pervasive developmental disorders

24 2.46 71 7.68 <.0001*

Psychotic disorders 16 1.64 69 7.47 <.0001*Substance abuse disorders 60 6.15 65 7.03 .44

Note: Cell sizes less than 30 are italicized indicating caution while interpreting results. *Statistically significant differences between Regular Foster Care and Non‐Foster Care children.

34

71.00*

91.67*

29.00

8.33

0

20

40

60

80

100

Regular foster care (n=976) ISCEDC (n=724)


Received psychiatric services

Did not receive psychiatric services

Figure 2.13. Receipt of psychiatric services by status;



Figure 2.13 displays the comparison of regular

foster care and ISCEDC children who received

psychiatric services as adjunct to the

pharmacological treatment during the study

period. The majority of each group received

psychiatric services. However, there was a

significant difference in receipt of psychiatric

services among regular foster care and ISCEDC

children with nearly 92% of the ISCEDC

children receiving psychiatric services

compared to 71% of the regular foster care

children (p<.0001).

Receipt of psychiatric services was also

examined to see if there were any gender

differences within each group. As indicated in

Figure 2.14, there were no significant

statistical differences in receipt of psychiatric

services among either group by sex. Nearly

73% of females and 70% of males in the

regular foster care category received

psychiatric services during the study period.

Nearly 91% of males and 93% of females in

ISCEDC category received psychiatric services.

69.86

90.72

72.57

92.99

0

20

40

60

80

100

Regular foster care (n=976) ISCEDC (n=924)

% Children Who Received Psychiatric Servicesby Sex and Status

Male Female

Figure 2.14. Receipt of psychiatric services by sex and status.

35

Section IV: Comparisons between children in adoption and regular foster care categories


of psychiatric services in addition to the pharmacologic treatment among children in adoption category

and regular foster care category.

Table 2.13 indicates the socio‐demographic characteristics of children in regular foster care and adoption

categories who received at least one psychotropic prescription in CY 2011.

Table 2.13. Characteristics of SC Medicaid Children in Regular Foster Care and Adoption Categories Who Received at Least One Psychotropic Medication Prescription in CY2011

Characteristic Regular Foster Care (n=976) Adoption (n=2,252)

p value n† % n† %

Sex .63 Male 564 57.79 1,322 58.70 Female 412 42.21 930 41.30 Age in years [Mean (SD)] [12.03 (0.15)] [12.21 (0.08)] <.0001 < 1 ‐‐‐ ‐‐‐ ‐‐‐ ‐‐‐ 1‐4 38 3.89 40 1.78 5‐9 274 28.07 572 25.40 10‐14 320 32.79 952 42.27 15‐17 200 20.49 461 20.47 18‐21 140 14.34 227 10.08 Race .0002 White 488 50.00 1,110 49.29 African American 434 44.47 919 40.81 Other 54 5.53 223 9.90 Clinical risk group .03 Healthy/moderate 361 36.99 927 41.16 Severe/catastrophic 615 63.01 1,325 58.84 Rurality‡ .005 Urban 721 73.87 1,596 70.87 Large rural 173 17.73 386 17.14 Small rural 62 6.35 170 7.55 Isolated rural 18 1.84 98 4.35 PSADI‡ <.0001 Low‐moderate deprivation 660 67.62 1,880 83.48 High rural deprivation 109 11.17 242 10.75 High urban deprivation 205 21.00 128 5.68 Recorded psychiatric diagnosis 911 93.34 2,025 89.92 .002Receipt of psychiatric services 693 71.00 1,040 46.18 <.0001


36



More than two thirds of children in both categories received mono‐class treatment. As indicated in Table

2.14 below, among these children, the top three drug classes prescribed included ADHD medications

followed by antidepressants and antipsychotics irrespective of the child’s status (regular foster care vs.

adoption). Significantly more children in adoption category received prescriptions for ADHD medications

(84.86%) compared to regular foster care children (77.46%). On the other hand, significantly less children

in adoption category received antidepressants (23.62%) compared to their regular foster care peers

(30.74%). There were no significant differences in receipt of antipsychotics, anticonvulsants, and

antianxiety medications among the two groups (Table 2.14).

Table 2.14. Proportion of Regular Foster Care and Adoption Children Receiving Specific Psychotropic Drug Classes in CY 2011

Psychotropic Drug Class Regular Foster Care (n=976) Adoption (n=2,252) p value

n % n %

ADHD medications 756 77.46 1,911 84.86 <.0001*

Antianxiety medications 37 3.79 79 3.51 .69Anticonvulsants 111 11.37 287 12.74 .28Antidepressants 300 30.74 532 23.62 <.0001*Antipsychotics 148 15.16 381 16.92 .22Barbiturate sedatives 9 .92 ‐‐‐ ‐‐‐ ‐Mood stabilizers 6 .61 16 .71 .76Non‐barbiturate sedatives 25 2.56 20 .89 .0002*

Note: ‐‐‐ Cell sizes less than 6 observations are suppressed. ‐ Indicates p values not reported due to very small sample size. Italicized numbers indicate cell sizes less than 30 indicating caution while interpreting the results. * Statistically significant differences.

The two groups (adoption and regular foster care) did not differ significantly by gender.

Children in adoption category were significantly less likely to be categorized under severe‐to‐catastrophic CRG compared to those from the regular foster care category (58.84% vs. 63.01% respectively).

Children in adoption category were significantly less likely to have a listed psychiatric diagnosis compared to regular foster care children (89.92% vs. 93.34% respectively).

Children in adoption category were significantly less likely to receive psychiatric services in addition to the pharmacologic treatment compared to their regular foster care peers (46.18% vs. 71.0% respectively).

37

The top three drug combinations among children in adoption category included ADHD medications and

antidepressants (n=201, 8.93%), ADHD medications and antipsychotics (n=140, 6.22%), and ADHD

medications and anticonvulsants (n=52, 2.31%).

Among those who received multi‐class treatment, no significant differences were found by status (Table

2.15). Less than a third of children under adoption category received psychotropic medications from two

or more classes.

Table 2.15. Multi‐class Psychotropic Treatment Patterns Among Regular Foster Care and Adoption Children Who Received Psychotropic Prescriptions in CY 2011

Type of Multi‐class Psychotropic Treatment

Regular Foster Care (n=976) Adoption (n=2,252) p value

n % n %

Two or more drug classes 311 31.86 685 30.42 .41

Three or more drug classes 87 8.91 219 9.72 .47

Four or more drug classes 18 1.84 66 2.93 .07



Table 2.16 indicates reported psychiatric diagnoses among the children in regular foster care and

adoption categories. Children in adoption category were more likely to receive the diagnosis of ADHD

compared to their regular foster care peers (80.33% vs. 76.23% respectively). In contrast, regular foster

care children were significantly more likely to be diagnosed with adjustment disorders (44.47%), anxiety

disorders (9.63%), disruptive behavior disorders (30.33%), mood disorders (28.38%), and substance abuse

disorders (6.15%) compared to their peers in adoption category (Table 2.16).

Table 2.16. Reported Psychiatric Diagnoses Among Regular Foster and Adoption Children


Regular Foster Care (n=976)

Adoption (n=2,252) p value*

n % n %

ADHD 744 76.23 1,809 80.33 .0085*Adjustment disorders 434 44.47 415 18.43 <.0001*Anxiety disorders 94 9.63 162 7.19 .02*Disruptive behavior disorders 296 30.33 452 20.07 <.0001*Mood disorders 277 28.38 422 18.74 <.0001*Pervasive developmental disorders 24 2.46 121 5.37 .0002*Psychotic disorders 16 1.64 23 1.02 .14Substance abuse disorders 60 6.15 39 1.73 <.0001*

Note: Cell sizes less than 30 are italicized indicating caution while interpreting results. *Statistically significant differences between Regular Foster Care and Adoption children.

38

71.00*

46.18*

29.00

53.82

0

20

40

60

80

100

Regular foster care (n=976) Adoption (n=2,252)


Received psychiatric servicesDid not receive psychiatric services

Figure 2.15. Receipt of psychiatric services by status;



Figure 2.15 displays the comparison of

children in regular foster care and

adoption categories who received

psychiatric services as adjunct to the

pharmacological treatment during the

study period. Less than half of children

under adoption category received

psychiatric services. In comparison,

more than 70% of children in regular

foster care received psychiatric services.

This was a statistically significant

difference (p<.0001) between the two

groups.

Receipt of psychiatric services was also examined to see if there were any gender differences within each

group. As indicated in Figure 2.16, there were no significant statistical differences in receipt of psychiatric

services among either group by sex. Nearly 73% of females and 70% of males in the regular foster care

category received psychiatric services during the study period. Slightly more than 46% of males and

approximately 46% of females in

adoption category received

psychiatric services.

69.86

46.37

72.57

45.91

0

20

40

60

80

100

Regular foster care (n=976) Adoption (n=2,252)

% Children Who Received Psychiatric Services by Sex and Status

Male Female

Figure 2.16. Receipt of psychiatric services by sex and status.

39

CHAPTER 3: ANTIPSYCHOTIC PRESCRIPTION CLAIMS

As mentioned earlier, use of antipsychotic

medications is increasing among children and

adolescents. Antipsychotic medications are

classified into two major categories:

conventional and newer antipsychotics.

Conventional antipsychotic medications, also

called typical or first generation antipsychotics,

can cause serious side effects including extra‐

pyramidal side effects, weight gain, heart

disease, diabetes, pancreatitis, and other

metabolic disorders. Atypical or second

generation antipsychotics are effective and

cause fewer side effects compared to

conventional antipsychotics. For the list of

typical and atypical antipsychotics, please refer

to Appendix B1. Prescription patterns of antipsychotics in children enrolled in SC Medicaid during the

study period are presented here.

Profile of Children Receiving Prescriptions of Antipsychotic Medications

Of the total sample who received psychotropic medications, 7,221 (11.49%) received antipsychotic

prescriptions in CY 2011. Table 3.1 describes the profile of these children.

Demographic characteristics:

Irrespective of the child status, males were more likely to receive antipsychotic prescriptions

compared to females. The average age of children receiving antipsychotics was about 13.5 years.

Among both foster care and non‐foster care subsamples, the largest proportions of children receiving

antipsychotics were in the age groups of 10‐14 years followed by 15‐17 years. Thirty‐four children

under the age of 5 years received antipsychotic prescriptions. However, when the cut‐off point was

raised to include 5‐year olds, 112 children received antipsychotics. The proportion of African

American children receiving antipsychotics was higher in the regular foster care subsample (49.32%)

compared to non‐foster subsample (23.03%). Approximately 30% of children receiving antipsychotic

medications lived in rural areas. When examined by social deprivation indicator, overall 17.16% of

the sample lived in high deprivation areas.

Foster care status:

The majority of children receiving antipsychotics were non‐foster children (86.46%). Among all foster

care children (n=978), the largest proportions of children receiving antipsychotics belonged to ISCEDC

(44.93% of all fosters, 6.08% of total) category followed by adoption category (39.00% of all fosters,

5.28% of total).

40

Clinical characteristics:

The majority of children receiving antipsychotics were categorized under severe to catastrophic

clinical risk group (CRG) categories (92.62%). The proportions of children classified as severe‐to‐

catastrophic CRG did not differ significantly (p=.07) between regular foster children (88.51%) and

non‐foster children (92.54%) as well as between regular foster and adoption children (90.55%, p=48).

However, significantly more children under ISCEDC category (96.81%) were classified as severe‐to‐

catastrophic CRG compared to their regular foster peers (p<.0001). All children in regular foster care

category and nearly all children in ISCEDC category had listed psychiatric diagnoses. Compared to

regular foster care children, significantly lower proportions of non‐foster children (95%) and adoption

children (96%) had listed psychiatric diagnoses (p=.006 and p=.018 respectively). There were

significant differences in receipt of psychiatric services between children in regular foster care and

non‐foster care (p<.0001) as well as regular foster care and adoption categories (p=.0002).

Table 3.1. Selected Characteristics of SC Medicaid Children in Receipt of at Least One Antipsychotic Prescription in CY2011

Characteristic Total

(n=7,221) n (%)

Non‐Foster (n=6,243) n (%)

Reg. Foster (n=148) n (%)

ISCEDC (n=439) n (%)

Adoption (n=381) n (%)

Sex Male 4,979 (68.95) 4,366 (69.93) 96 (64.86) 270 (61.50) 242 (63.52)Female 2,242 (31.05) 1,877 (30.07) 52 (35.14) 169 (38.50) 139 (36.48)

Age [Mean (SD)] [13.5 (.05)] [13.45 (.05)] [14.07 (0.33)] [14.37 (0.14)] [13.04(0.19)] < 1 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 1‐4 34 (0.47) 29 (.46) ‐‐‐ 0 (0.00) ‐‐‐ 5‐9 1,368 (18.94) 1,227 (19.65) 22 (14.86) 39 (8.88) 79 (20.73) 10‐14 2,669 (36.96) 2,318 (37.13) 47 (31.76) 153 (34.85) 149 (39.11) 15‐17 1,528 (25.27) 1,482 (23.74) 42 (28.38) 193 (43.96) 103 (27.03) 18‐21 1,325 (18.35) 1,187 (19.01) 35 (23.65) 54 (12.30) 47 (12.34)

Race White 3,354 (46.45) 2,949 (47.24)a 65 (43.92)a, b 160 (36.45)b 180 (47.24)African American 1,850 (25.62) 1,438 (23.03)a 73 (49.32)a, b 162 (36.90)b 175 (45.93)Other 2,017 (27.93) 1,856 (29.73)a 10 (6.76)a, b 117 (26.65)b 26 (6.82)

Status Non‐foster care 6,243 (86.46) 6,243 (100.00) N/A N/A N/AAll foster care 978 (13.54) Adoption† 381 (5.28) N/A N/A N/A 381 (100.00)ISCEDC† 439 (6.08) N/A N/A 439 (100.00) N/AMCC† 10 (.14) N/A N/A N/A N/ARegular foster† 148 (2.05) N/A 148 N/A N/A

Clinical risk group Healthy/moderate 533 (7.38) 466 (7.46) 17 (11.49) b 14 (3.19)b 36 (9.45)Severe/catastrophic 6,688 (92.62) 5,777 (92.54) 131 (88.51)b 425 (96.81)b 345 (90.55)

41

68.95 69.9364.86 63.52 61.5

31.05 30.0735.14 36.48 38.5

0

20

40

60

80

100

Total(n=7,221)

Non‐fostercare (n=6,243)


Adoption(n=381)

ISCEDC(n=439)

Proportion (%) of Children Receiving Antipsychotics by Sex and Status

Male Female

Figure 3.1. Receipt of antipsychotics among SC Medicaid children by sex and status.

Characteristic Total

(n=7,221) n (%)





Rurality‡

Urban 5,064 (70.13) 4,352 (69.71) 105 (70.95) 341 (77.68) 259 (67.98)Large rural 1,425 (19.73) 1,263 (20.23) 22 (14.86) 69 (15.72) 69 (18.11)Small rural 446 (6.18) 380 (6.09) 17 (11.49) 21 (4.78) 27 (7.09)Isolated rural 280 (3.88) 243 (3.89) ‐‐‐ 8 (1.82) 25 (6.56)

Deprivation Index PSADI‡

Low‐moderate 5,976 (82.76) 5,242 (83.97)a 108 (72.97)a, b 321 (73.12)b 297 (77.95)High rural 670 (9.28) 556 (8.91) a 23 (15.54) a, b 35 (7.97) b 56 (14.70)High urban 569 (7.88) 440 (7.05) a 17 (11.49) a, b 83 (18.91) b 27 (7.09)Psychiatric diagnosis 6,900 (95.55) 5,940 (95.15)a 148 (100.00)a, c 437 (99.54) 367 (96.33)c

Psychiatric services 4,917 (68.09) 4,124 (66.06)a 128 (86.49)a, c 392 (89.29) 269 (70.60)c

Note: ‐‐‐ Cell sizes less than 6 observations are suppressed. Italicized estimated percentages are based on fewer than 30 observations and thus are statistically unreliable.

† Adoption, ISCEDC, MCC, and Regular Foster are subcategories of foster care. ‡ Columns may not total 100% due to rounding and missing values. a Statistically significant difference between Regular Foster Care and Non‐Foster Care children. b Statistically significant difference between Regular Foster Care and ISCEDC children. c Statistically significant difference between Regular Foster Care and Adoption children.

Patterns of Antipsychotic Drug Prescriptions by Child Status, Gender, and Age

Figure 3.1 describes distribution

of children receiving

antipsychotic prescription by sex

and status. (Please note that

MCC category is not shown since

only 10 children in this category

received antipsychotic

medications.) Males were

significantly more likely to

receive antipsychotic

prescriptions compared to

females across all status

categories.

42

As indicated in Table 3.2, the majority of children receiving antipsychotic medications received multi‐class

treatment (87.83%). Of the children receiving antipsychotics, approximately 44% received medications

from three or more psychotropic drug classes and approximately 13% received medicines from four or

more drug classes. Significantly more children in ISCEDC category received three or more psychotropic

drug classes compared to those in regular foster care (p=.008). Further, among 112 children aged 5 years

or younger who received antipsychotics, nearly 3 out of every 4 children received multi‐class treatment.

Table 3.2. Type of Psychotropic Treatment (Mono‐Class vs. Multi‐Class) Among Children Receiving Antipsychotic Prescriptions by Status

Treatment Type Total (n=7,221)

Non‐Foster (n=6,243)

Reg. Foster (n=148)

ISCEDC

(n=439)

Adoption (n=381)

Mono‐class 879 (12.17%) 788 (12.62%) 12 (8.11%) 39 (8.88) 38 (9.97%)

Two or more drug classes

6,342 (87.83%) 5,455 (87.38%) 136 (91.89%) 400 (91.12) 343 (90.03%)

Three or more drug classes

3,184 (44.09%) 2,703 (43.30) 64 (43.24)* 245 (55.81)* 169 (44.36%)

Four or more drug classes

945 (13.09%) 803 (12.86) 14 (9.46) 70 (15.95) 58 (15.22%)

* Statistically significant difference between children in regular foster care and ISCEDC categories.


Table 3.3 indicates psychiatric diagnosis categories among children who received antipsychotic

prescriptions. Irrespective of their foster care status, less than 10% of children who received

antipsychotic medication prescription had reported psychotic disorder diagnoses. Among children who

received antipsychotic medication prescriptions, the top three psychiatric diagnostic categories included

ADHD (79.05%), mood disorders (58.78%), and disruptive behavior disorders (50.00%) among regular

foster care children; ADHD (65.67%), mood disorders (46.16%), and disruptive behavior disorders

(36.78%) among the non‐foster children; ADHD (84.74%), disruptive behavior disorders (78.13%), and

mood disorders (74.03%) among ISCEDC children; and ADHD (76.12%), mood disorders (50.39%), and

disruptive behavior disorders (42.52%) among adoption children. Statistically significant differences were

found in adjustment disorders between non‐foster (14.56%) and regular foster (47.97%, p<.0001),

between ISCEDC (58.31%) and regular foster children (p=.03), and between adoption (24.15%) and

regular foster children (p<.0001).

Table 3.3. Reported Psychiatric Diagnoses Among Foster and Non‐Foster Children Who Received Antipsychotic Medication Prescription


Total (n=7,221)


Reg. Foster (n=148)

ISCEDC (n=439)

Adoption (n=381)

n (%) n (%) n (%) n (%) n (%)

ADHD 4,881 (67.59) 4,100 (65.67)a 117 (79.05)a 372 (84.74) 290 (76.12)

43


Total (n=7,221)


Reg. Foster (n=148)

ISCEDC (n=439)

Adoption (n=381)

n (%) n (%) n (%) n (%) n (%)

Adjustment disorders

1,329 (18.40) 909 (14.56)a 71 (47.97)a, b, c 256 (58.31)b 92 (24.15)c

Anxiety disorders 1,011 (14.00) 868 (13.90) 18 (12.16) 81 (18.45) 43 (11.29)

Disruptive behavior disorders

2,877 (39.84) 2,296 (36.78)a 74 (50.00)a, b 343 (78.13)b 162 (42.52)

Mood disorders 3,490 (48.33) 2,882 (46.16)a 87 (58.78)a, b 325 (74.03)b 192 (50.39)

Pervasive developmental disorders

1,321 (18.29) 1,204 (19.29)a 13 (8.78)a 47 (10.71) 53 (13.91)

Psychotic disorders 642 (8.89) 566 (9.07) 7 (4.73) b 51 (11.62)b 16 (4.20)

Substance abuse disorders

394 (5.46) 335 (5.37)a 15 (10.14)a 28 (6.38) 16 (4.20)

Note: Italicized estimated percentages are based on fewer than 30 observations indicating caution while interpreting p values which may be statistically unreliable. a Statistically significant difference between Regular Foster Care and Non‐Foster Care children. b Statistically significant difference between Regular Foster Care and ISCEDC children. c Statistically significant difference between Regular Foster Care and Adoption children.


Overall, more than two thirds of

children (68.09%) who received

antipsychotic prescriptions also

received psychiatric services.

Figure 3.2 indicates proportions of

children who also received

psychiatric services in addition to

antipsychotic prescriptions by

status. Regular foster care children

were significantly more likely than

non‐foster children and adoption

children to receive psychiatric

services (p<.0001 and p=.0002

respectively).

When compared by gender within

each status category, there were

66.06a

86.49a, b 89.29

70.60b

33.94

13.51 10.71

29.40

0

20

40

60

80

100

Non‐foster care(n=6,243)


ISCEDC (n=439) Adoption (n=381)


Received psychiatric services Did not receive psychiatric services

Figure 3.2. Receipt of psychiatric services as adjunct to antipsychotic treatment a Statistically significant difference between regular foster and non‐foster children. b Statistically significant difference between regular foster and adoption children.

44

no statistically significant

differences in receipt of

psychiatric services among

children who received

antipsychotic medications

(Figure 3.3).

Antipsychotic Medication Adherence

Administrative pharmacy claims can provide quality metrics about medication utilization patterns,

including compliance, adherence, and persistence. Health outcomes related to pharmacy utilization

include compliance, adherence, and persistence measurements.14 The following indicators of drug

therapy management are used in this study.

Medication possession ratio. The medication possession ratio (MPR) is a measure of patient adherence

or compliance and is defined as the sum of a medication’s days of supply divided by the total number of

days in a time interval. While the most commonly used measure of adherence, MPR may overestimate

medication adherence when prescriptions are refilled before the previous supply of medication is

depleted. Compliance thresholds are based on the type of medication, disease of interest, or population

under study and typically range from 60%‐80%. In this study, optimal compliance for psychotropic

prescriptions is defined as 80% compliance or adherence with medication utilization with a maximum of

1.0. The results are reported in Table 3.4.

Proportion of days covered. In contrast to MPR, the proportion of days covered is a more conservative

estimate of adherence that measures each day with a supply of the medication(s) of interest over a

specific time period. The International Society for Pharmacoeconomics and Outcomes Research (ISPOR)

has urged for greater use of PDC in medication utilization research and CMS and PQA release

pharmaceutical quality data with PDC measures.15 For this study, the time interval for PDC is 180 days or

6 months, which is an acceptable level of observation of clinicians for patients using antipsychotic

prescriptions. The findings are reported in Table 3.5.

65.48

86.46 88.15

70.6667.39

86.54 91.12

70.50

0

20

40

60

80

100

Non‐foster care(n=6,243)


ISCEDC (n=439) Adoption(n=381)


Male Female

Figure 3.3: Receipt of psychiatric services as adjunct to antipsychotic treatment by sex and status

45

Two common measures of medication utilization adherence are the Medication

Possession Ratio (MPR) or Proportion of Days Covered (PDC). Optimal adherence is

defined at 80% for both measures in the study. The PDC is a more conservative

estimate of medication utilization and evidence suggests the metric is a more reliable

estimation of adherence. However, the MDC is still widely used. In this report, both

measures are used to estimate adherence to psychotropic medications, specifically

antipsychotic medications, among Medicaid children in the sample.

A mean possession ratio (MPR) lower than 0.8 indicates poor adherence to the drug prescribed.

Adherence to typical antipsychotic drugs was lower than the threshold, which indicates suboptimal

compliance. However, the overall adherence to all antipsychotic drugs and atypical antipsychotic drugs

was in acceptable levels. To investigate the adherence level of antipsychotic drug utilization, the main

ingredient or compound was aggregated. For example, haloperidol includes the brand name drug Haldol

and generic haloperidol. Poor adherence was detected in medication utilization of four antipsychotic

medications: aripiprazole (MPR=0.797), chlorpromazine (MPR=0.779), haloperidol (MPR=0.772), and

loxapine (MPR=0.738; Table 3.4).

Mean possession ratios as a measure of medication utilization has been criticized due to potential

overestimates of medication adherence. Using this traditional metric, poor adherence was noted in the

use of four antipsychotic medications; however, overall, the adherence rate was acceptable for all

antipsychotic drugs. In contrast to MPR, no antipsychotic drugs met the adherence threshold of 0.8 using

the proportion of days covered (PDC) measure.

Table 3.4. Mean Medication Possession Ratio (MPR) for Antipsychotic Drugs

Drug Name N Lower 95% CL for Mean

Upper 95% CL for Mean

Mean Std Dev

Aripiprazole 3,184 0.7914 0.8028 0.7971 0.0029

Asenapine 42 0.5419 0.6995 0.6207 0.0397

Chlorpomazine 56 0.7403 0.8180 0.7791 0.0197

Clozapine 8 0.8195 0.9271 0.8734 0.0270

Droperidol 0 N/A N/A N/A N/A

Fluphenazine 16 0.8196 0.9271 0.8734 0.0270

Haloperidol 212 0.7474 0.7969 0.7721 0.01262

Iloperidone 25 0.8413 0.9193 0.8803 0.0197

Loxapine 5 0.5716 0.9039 0.7377 0.0791

Lurasidone 15 0.7805 0.9120 0.8463 0.0329

Molidone 3 0.7318 0.9738 0.8528 0.0578

Olanzapine 582 0.8210 0.8445 0.8328 0.0060

Paliperidone 231 0.8498 0.8797 0.8647 0.0076

Perphenazine 16 0.8364 0.9402 0.8883 0.0262

46

Drug Name N Lower 95% CL for Mean


Mean Std Dev

Pimozide 15 0.8177 0.9310 0.8744 0.0288

Quetiapine 2,073 0.8290 0.8415 0.8352 0.0032

Risperidone 5,270 0.8179 0.8257 0.8218 0.0020

Thioridazine 10 0.3507 0.6659 0.5083 0.0785

Thiothixene 11 0.3029 0.4354 0.3692 0.0317

Trifluperazine 3 0.8773 0.9781 0.9277 0.0258

Ziprasidone 738 0.8431 0.8626 0.8529 0.0050

Atypical antipsychotics 5,562 0.8176 0.8253 0.8215 0.0020

Typical antipsychotics 313 0.7576 0.7975 0.7776 0.0101

All Antipsychotics 5,875 0.8184 0.8261 0.8222 0.0019 The most commonly prescribed antipsychotic drugs to Medicaid patients in the sample were risperidone

(brand name risperidol), aripiprazole, quetiapine, olanzapine, paliperidone, and haloperidol (Table 3.4).

Antipsychotic drug adherence was greatest in children with a risperdone prescription (PDC=0.644; Table

3.4). Among the most commonly prescribed antipsychotic drugs, adherence was lowest in children

prescribed haloperidol (PDC=0.506; Table 3.5).

Table 3.5. Proportion of Days Covered (PDC) for Antipsychotic Drugs

Drug Name (Brand) N Median Lower 95% CL for Mean


Mean Std Dev

Aripiprazole (Abilify) 3184 0.6667 0.6038 0.6251 0.6145 0.0054

Asenapine (Sahpris) 42 0.3333 0.3155 0.4784 0.3970 0.0403

Chlorpomazine (Thorazine)

56 0.3333 0.3568 0.5263 0.4416 0.0423

Clozapine (Chlorazil, Fazacla)

8 0.5889 0.2513 0.8904 0.5708 0.1352

Droperidol (Inapsine) 0 N/A N/A N/A N/A N/A

Fluphenazine (Prolixin) 16 0.5000 0.4223 0.7013 0.5618 0.0655

Haloperidol (Haldol) 212 0.4556 0.4606 0.5511 0.5059 0.0230

Iloperidone (Fanapt) 25 0.6667 0.4937 0.7574 0.6255 0.0639

Loxapine (Loxatine) 5 0.3333 0.0533 0.9045 0.4789 0.1533

Lurasidone (Latuda) 15 0.6667 0.4345 0.7921 0.6133 0.0834

Molidone (Moban) 3 0.5000 0.2573 1.4499 0.5963 0.1984

Olanzapine (Zyprexa) 582 0.6278 0.5585 0.6116 0.5850 0.0135

Paliperidone (Invega) 231 0.6944 0.5872 0.6707 0.6290 0.0212

Perphenazine (Trilafon) 16 0.4167 0.3126 0.6936 0.5031 0.0894

Pimozide (Orap) 15 0.6833 0.4736 0.8189 0.6463 0.0805

Quetiapine (Seroquel) 2073 0.666 0.6006 0.6275 0.6140 0.0068

Risperidone (Risperdol) 5270 0.6667 0.6355 0.6518 0.6437 0.0042

Thioridazine (Mellaril) 10 0.3639 0.2499 0.6456 0.4478 0.0875

Thiothixene (Nevane) 11 0.3333 0.2051 0.4040 0.3045 0.0446

Trifluperazine (Stelazine) 3 0.8944 0.4961 1.2372 0.8667 0.0861

Ziprasidone (Geodon) 738 0.6389 0.5709 0.6178 0.5943 0.0120

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Drug Name (Brand) N Median Lower 95% CL for Mean


Mean Std Dev

Atypical antipsychotics 5562 0.6667 0.6343 0.6503 0.6423 0.0041

Typical antipsychotics 313 0.5000 0.4820 0.5546 0.5183 0.0185

All Antipsychotics 5,875 0.6667 0.6344 0.6503 0.6423 0.0041

Presence of Selected Non‐Psychiatric Diagnoses that Need Close Monitoring

Antipsychotic medications, particularly first generation antipsychotics are associated with side effects

including weight gain, cardiovascular complications, neurologic problems and movement disorders,

hyperglycemia, diabetes, pancreatitis, disorders of lipid metabolism, and metabolic syndrome X.

Presence of these diagnoses in children receiving antipsychotic medications needs careful clinical

monitoring. Table 3.6 displays the number of children who had above mentioned diagnoses and were

receiving antipsychotic medications. Please note that due to small cell sizes, regular foster care, ISCEDC,

adoption, and MCC categories are collapsed into one category of all foster care. Overall, 1,213 (16.8%) of

children receiving antipsychotic prescriptions also had one of the above mentioned medical conditions

listed on the claims data. There were no statistically significant differences overall or by selected

diagnostic conditions among all foster care and non‐foster children. Out of 978 foster children and 6,243

non‐foster children receiving antipsychotic prescriptions, 156 (15.95%) foster children and 1,057 (16.93%)

non‐foster children had one of these non‐psychiatric conditions.

Table 3.6. Proportion of Children With Antipsychotic Prescription Who Had Selected Non‐Psychiatric Diagnoses That Need Close Monitoring

Diagnosis Total (N=7,221) All Foster Care

(N=978) Non‐Foster Care

(N=6,243)

n % n % n %

Cardiovascular conditions 441 6.11 57 5.83 384 6.15Diabetes 224 3.10 30 3.07 194 3.11Disorders of lipid metabolism 229 3.17 32 3.27 197 3.16Hyperglycemia 81 1.12 10 1.02 71 1.14Metabolic syndrome X 61 .84 ‐‐‐ ‐‐‐ 58 .93Neurologic problems and movement disorders

48 .66 10 1.02 38 .61

Pancreatitis 18 .25 ‐‐‐ ‐‐‐ 17 .27Secondary diabetes 6 .08 0 0 6 .1Weight gain/obesity 447 6.19 54 5.52 393 6.30

Note: All Foster Care category includes regular foster care, ISCEDC, adoption, and MCC categories. ‐‐‐ Cell sizes with less than 6 observations are suppressed. Italicized estimated percentages are based on fewer than 30 observations indicating caution while interpreting the results.

48

CHAPTER 4: DISCUSSION

Summary of the Findings

The purpose of this report is to describe psychotropic

prescription patterns in children enrolled in the SC

Medicaid program. A total of 62,859 children who

received psychotropic medications in CY 2011 were

included in the sample. In a retrospective analysis of

prescription claims from CY 2009 through CY2011, the

prescription patterns of psychotropic medications,

associated psychiatric diagnoses, and receipt of

psychiatric services as an adjunct to pharmacological

treatment were examined.

The majority of the approximately 63,000 children in the

sample did not belong to the foster care system and were

more likely to be White, male, and live in urban areas.

Among children in regular foster care, the proportion of

males was 57.8%. Nationally, an estimated 52% of

children in foster care in 2010 were males. 16 More

children in foster care category receiving psychotropic

medications were African American, older, and lived in

socially deprived urban areas compared to their non‐

foster peers. In a measure of risk of clinical diagnoses,

foster care children had higher rates of severe or complex

clinical conditions. It should be noted that the regular

foster care category excluded children who were adopted

or classified as ISCEDC or MCC.

Prescribing patterns of the eight psychotropic drug classes were examined during the study period. More

than three quarters of the children in the sample received prescriptions from a single psychotropic drug

class. Significantly more children in regular foster care received psychotropic medications from multiple

drug classes compared to non‐foster children. This could be attributed to higher need of psychotropic

medications among foster care children due to their vulnerability to biological, psychological, and social

risk factors that are commonly associated with foster care status. However, it is also possible that there

may be provider bias in prescribing medications from multiple psychotropic drug classes for foster care

children compared to non‐foster children. Among the foster care children, children in ISCEDC category

were significantly more likely to receive multi‐class treatment compared to regular foster care children.

These differences persisted whether the cut‐off is selected at two or more; three or more; or four or

more drug classes for defining multi‐class psychotropic treatment. This could be attributed to higher

mental health needs among children in ISCEDC category compared to their regular foster peers. The most

commonly prescribed psychotropic drug class combinations included ADHD medications‐antidepressants

followed by combination of ADHD medications‐antipsychotics irrespective of the child’s status.

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ADHD and antidepressant medications were the top two psychotropic prescriptions among children

irrespective of their status. Males were more likely to receive ADHD medications and females were more

likely to receive antidepressants compared to their respective peers. Nearly one out of two children in

ISCEDC category receiving psychotropic medications received prescription for antipsychotic medication.

The proportion of ISCEDC children who received antipsychotic prescriptions was nearly 3 times the

proportion of regular foster children who received antipsychotic prescriptions. In contrast, the proportion

of non‐foster children receiving antianxiety medications was nearly 2 times the proportion of all foster

care children receiving antianxiety medications. Small proportions of children received barbiturate

sedatives, mood stabilizers, and non‐barbiturate sedatives irrespective of their foster care status. Among

children receiving antipsychotic prescriptions, nearly 88% children received multi‐class treatment. A

significantly higher proportion of regular foster care children (~92%) on antipsychotics, received multi‐

class treatment compared to non‐foster children on antipsychotics (~87%). Further, slightly more than

13% of the total children with antipsychotic prescriptions received prescriptions from four or more

psychotropic drug classes. This proportion was higher compared to previously reported rates of 11.8% in

2004 and 10.9% in 2007 among children and adolescents from 16 states in the analysis of psychotropic

medication use. 17 Another area of concern found among children receiving antipsychotic prescription

was that 112 children, majority being non‐foster children, aged 5 years or younger received antipsychotic

medications. Further, nearly three fourths of these children (82 out of 112) received multi‐class

treatment. In a report by the Medicaid Medical Directors Learning Network and Rutgers Center for

Education and Research on Mental Health Therapeutics, the use of antipsychotic medications among

children 5 years or younger and use of multiple mental health drugs (four or more) during a calendar year

were considered as preliminary measures to indicate potential quality and safety issues in psychotropic

pharmacological treatment. 17

In a measure of adherence to antipsychotic medications, overall adherence was within acceptable levels

using the calculated mean possession ratio. In a comparison of typical and atypical antipsychotic

medications, adherence to typical or conventional antipsychotic medications was lower than the

threshold level indicating optimal compliance. Lower adherence was noted using a more conservative

estimate of medication compliance. However, there is a lack of consensus about the appropriate

measure to use in children receiving psychotropic medications.

ADHD was the most common psychiatric diagnosis reported among children in the sample irrespective of

their foster care status. Adjustment disorders, disruptive behavior disorders, and mood disorders

followed ADHD among regular foster care children while disruptive behavior disorders, mood disorders,

and adjustment disorders followed ADHD among non‐foster care children. It was noteworthy to find that

nearly 17% of children who received psychotropic prescriptions had no listed psychiatric diagnosis in their

claims data. This proportion (no listed psychiatric diagnosis) was significantly lower among regular foster‐

care children compared to non‐foster care children. Among non‐foster children, nearly one in five

children who received mono‐class psychotropic treatment and one in ten who received multi‐class

treatment did not have listed psychiatric diagnosis. This is certainly an area of concern since there may be

cases where children are receiving psychotropic medications without indication. Among children who

received antipsychotic medications (which are prescribed to treat a psychotic disorder such as

schizophrenia, delusions, or other psychosis), less than 10% had a diagnosis of psychotic disorder. None

of the children receiving antipsychotics had a listed diagnosis of schizophrenia. It is possible that

50

providers refrain from assigning a schizophrenia diagnosis to children given its serious implications due to

associated stigma. Very few were diagnosed with delusional disorder. The majority of the children with a

psychotic disorder diagnosis had received a diagnosis of “other psychotic condition.” Nearly 66% of non‐

foster, 80% of regular foster, 79% of ISCEDC, and 76% of adoption children receiving antipsychotics were

diagnosed with ADHD.

In general, it is recommended that psychotropic pharmacotherapy be combined with other evidence‐

based protocols such as psychotherapy, family skills training or behavior management, etc. Overall,

slightly more than one third of all children received psychiatric services as adjunct to pharmacological

treatment. Such low rates of receiving psychiatric services could possibly be due to higher reliance on

pharmacological treatment than other psychiatric services by providers or by shortage of child and

adolescent psychiatrists and clinical psychologists. More than 70% of regular foster care children, in

contrast to only about a third of non‐foster children, received psychiatric services. It is not clear why the

majority of non‐foster children did not receive adjunct psychiatric services. There is a possibility that

providers may offer psychiatric services as adjunct to pharmacotherapy in foster care children due to

their unique circumstances and new family dynamics. The highest proportion of children receiving

psychiatric services was among children in ISCEDC category where nine out of ten children received such

services. This was an expected finding since children in ISCEDC category have emotional instability and

need more psychiatric services. The proportion of children receiving psychiatric services was also higher

among those receiving antipsychotic medications with nearly seven out of every ten children receiving

the adjunct services.

In the ISCEDC category, nearly three in four children received ADHD medications and nearly one in two

children received antidepressants and antipsychotics. Further, nearly 63% of ISCEDC children received

medications from two or more psychotropic drug class. Even when the cut‐off point for defining a multi‐

class treatment was raised to the receipt of three or more drug classes, nearly 30% of ISCEDC children fell

under the multi‐class treatment category. These findings reflect a greater vulnerability of these children

and higher need to provide quality mental health care to children with emotional disturbances. Children

in adoption category were found to be significantly less likely to have received antidepressants compared

to their regular foster peers. It is possible that children once adopted may perceive that they have a

secured “home” environment and feel less depressed compared to regular foster care children.

Many children in the foster care system have a myriad of complex health needs, which require care

coordination of “preventive, diagnostic, and treatment services.” 18 Higher rates of primary care and

behavioral health utilization were reported in foster care children and the delivery of such services was

often fragmented and episodic. 18 Similar to the national trends, more children in regular foster and

ISCEDC categories in our sample lived in areas with high social deprivation compared to those in non‐

foster category and had more severe or complex clinical risk categories. Within the levels of foster care,

ISCEDC and MCC children had even higher rates of high risk clinical diagnoses and ISCEDC and adoption

children were prescribed antipsychotic drugs more often than regular foster care children. Overall, the

health profile and psychotropic medication utilization patterns in SC Medicaid children in this sample

suggest the need for the delivery of quality pediatric mental health services using coordinated,

comprehensive, and patient‐centered mechanisms.

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The complexity of delivering quality and efficient services to foster care children is illustrated in the figure

below (Figure 4.1).18 In addition to the care coordination across service providers, the figure also

illustrates the complexity of navigating different structural and policy divisions across state agencies, such

as the Department of Social Services (DSS), Department of Mental Health (DMH), and the Department of

Health and Human Services (DHHS). As a foster care child moves through various outlets in the model,

there is an opportunity to strengthen the safety net of health services available with continuous

monitoring of performance measures and patient outcomes.

The study findings with this population of children in SC Medicaid can inform strategic policy initiatives and quality improvement efforts of the policymakers and stakeholders represented in the health care delivery model for children in foster care.

Previously Recommended Protocol Standards and Psychotropic Drug Safety

The American Academy of Child and Adolescent Psychiatry (AACAP) has issued several practice

parameters for delivery of care from both the patient and clinician perspectives. One of the AACAP

practice parameters for clinicians is an overview of the use of psychotropic medication in children and

adolescents.1 This parameter consists of five sections including assessment, development of treatment

Figure 4.1. Health Care Delivery Model for Children in Foster Care [Source: Inkelas M & Halfon N.(2002). Medicaid and Financing of Health Care for Children in Foster Care: Findings from a National Survey. UCLA Center for Health Children, Families, and Communities. Policy Brief Series.]

52

and monitoring plan, psycho‐education and assent/consent procedures, implementation of treatment

and monitoring plan, and management of complex pharmacological interventions. Thirteen principles

related to each of these five sections (Table 4.1), intended for clinicians, are based on evidence and

professional consensus among clinicians.1

Table 4.1. AACAP Practice Parameters for Use of Psychotropic Medications Among Children

AACAP Practice Parameter

AACAP Principles

Assessment 1. Before initiating pharmacotherapy, a psychiatric evaluation is completed.

2. Before initiating pharmacotherapy, a medical history is obtained, and a medical evaluation is considered when appropriate.

3. The prescriber is advised to communicate with other professionals involved with the child to obtain collateral history and set the stage for monitoring outcome and side effects during the medication trial.

Development of treatment and monitoring plan

4. The prescriber develops a psychosocial and psychopharmacological treatment plan based on the best available evidence.

5. The prescriber develops a plan to monitor the patient, short and long term.

6. Prescribers should be cautious when implementing a treatment plan that cannot be appropriately monitored.

Assent and consent for treatment

7. The prescriber provides feedback about the diagnosis and educates the patient and family regarding the child’s disorder and the treatment and monitoring plan.

8. Complete and document the assent of the child and consent of the parents before initiating medication treatment and at important points during treatment.

9. The assent and consent discussion focuses on the risks and benefits of the proposed and alternative treatments.

Implementation of treatment and monitoring plan

10. Implement medication trials using an adequate dose and for an adequate duration of treatment.

11. The prescriber reassesses the patient if the child does not respond to the initial medication trial as expected.

12. The prescriber needs a clear rationale for using medication combinations.

Management of complex pharmacological interventions

13. Discontinuing medication in children requires a specific plan.

Specific to children in state custody, AACAP has issued a position statement and guidelines for best

principles on the oversight of psychotropic medication use for children in state custody.8 Six basic

principles are outlined to improve psychiatric care of children in state custody. In addition, four

guidelines are proposed to assist states in developing state‐specific psychotropic medication oversight

programs with minimal, recommended, and ideal strategies for implementation. First, states are advised

53

to establish policies and procedures to guide psychotropic medication management with accompanying

strategies of minimal, recommended, and ideal impact. Secondly, states are cautioned to design and

improve oversight procedures within a collaborative body of child welfare agencies and adolescent

psychiatrists. Other best practices guidelines are to design a consultation program and create a website

to disseminate information to various stakeholders, including clinicians, caregivers, and foster parents

(Table 4.2).

Table 4.2. AACAP Guidelines for Psychotropic Medication Use Among Foster Care Children

AACAP Best Principles Guidelines Strategies

Establish policies and procedures to guide the psychotropic medication management of youth in state custody

Identify the parties empowered to consent for treatment for youth in state custody in a timely fashion [minimal].

Establish a mechanism to obtain assent for psychotropic medication management from minors when possible [minimal].

Obtain simply written psycho‐educational materials and medication information sheets to facilitate the consent process [recommended].

Establish training requirements for child welfare, court personnel and/or foster parents to help them become more effective advocates for children and adolescents in their custody [ideal].

Design and implement effective oversight procedures

Establish guidelines for the use of psychotropic medications for youth in state custody [minimal].

Establish a program, administered by child and adolescent psychiatrists, to oversee the utilization of medications for youth in state custody [ideal].

Maintain an ongoing record of diagnoses, height and weight, allergies, medical history, ongoing medical problem list, psychotropic medications, and adverse medication reactions that are easily available to treating clinicians 24 hours a day [recommended].

Consultation program State child welfare agencies, the juvenile court, or other state or county agencies empowered by law to consent for treatment with psychotropic medications, should design a consultation program administered by child and adolescent psychiatrists [recommended].

Website State child welfare agencies, the juvenile court, or other state or county agencies empowered by law to consent for treatment with psychotropic medications, should create a website to provide ready access for clinicians, foster parents, and other caregivers to pertinent policies and procedures governing psychotropic medication management, psycho‐educational materials about psychotropic medications, consent forms, adverse effect rating forms, reports on prescription patterns for psychotropic medications, and links to helpful, accurate, and ethical websites about child and adolescent psychiatric diagnoses and psychotropic medications [ideal].

54

Other federal and state agencies have used the AACAP’s practice parameters and best practices

guidelines to evaluate the effectiveness of existing and planned psychotropic medication management

programs. The Medicaid Medical Directors Learning Network has issued similar recommendations

including state‐specific programs and policies to monitor psychotropic medications, a collaborative forum

to promote discussion of new and existing policies with diverse stakeholders, and creation of a repository

of state‐specific programs and best practices to increase dissemination of effective interventions.

In a GAO comparative analysis of psychotropic drugs prescribed for foster and non‐foster care children in

Medicaid, five states were rated in their implementation of AACAP best practices on six criteria. In the

GAO evaluation, Texas and Michigan programs were considered at the forefront of psychotropic

prescription oversight. For example, Texas has designed and implemented state‐specific practice

parameters for psychotropic medication utilization and continuously analyzes medication prescription

patterns using an overhauled claims data system. In addition, the state has implemented an adverse

event reporting system with retrospective chart review, case series, and single case reports. Minimal and

ideal requirements for psychotropic medication management oversight suggested by the GAO are

indicated below (Table 4.3).

Table 4.3. GAO Guidelines for Psychotropic Medication Management Oversight

Level Guideline

Minimal Establish guidelines for the use of psychotropic medications for children in state custody.

Ideal Oversight program includes an advisory committee to oversee a medication formulary and provide medication monitoring guidelines to practitioners who treat children in the child welfare system.

Ideal Oversight program monitors the rate and types of psychotropic medication usage and the rate of adverse reactions among youth in state custody.

Ideal Oversight program establishes a process to review non‐standard, unusual, and/or experimental psychiatric interventions with children who are in state custody.

Ideal Oversight program collects and analyzes data and makes quarterly reports to the state or county child welfare agency regarding the rates and types of psychotropic medication use. Make this data available to clinicians in the state to improve the quality of care delivered.

Ideal Maintain an ongoing record of diagnoses, height, and weight, allergies, medical history, ongoing medication problem list, psychotropic medications, and adverse medication reactions that are easily available to treating clinicians 24 hours a day.

Adapted from GAO Report, 2011.

In South Carolina, according to the SC Department of Social Services protocol, every child entering the

foster care system should complete initial mental health assessment within 24‐48 hours and initial

comprehensive medical assessment within 5 days of the entry into the system.19 Initial mental health

screening of a child can be conducted by mental health professional or a pediatrician. The protocol also

requires obtaining mental health and behavioral information regarding the child from the parents,

55

relatives, or others and sharing this information with the foster parents and providers in order to meet

the child’s mental health needs. However, there are no specific protocols related to prescriptions and use

of psychotropic medications among children enrolled in SC Medicaid including those in the foster care

system. Currently, the SC Department of Health and Human Services, SC Department of Social Services,

and SC Department of Mental Health are working together to develop guidelines and protocols for

prescribing psychotropic medications among SC Medicaid children including foster care children.

Recommendations

Based on the study findings and a brief review of established guidelines related to psychotropic

medication, the following recommendations are offered. There are several opportunities to improve the

oversight and management of psychotropic medications prescribed to children in Medicaid proactively

and in a holistic manner.

Recommendation 1:

Psychiatric diagnosis must be documented by applying specific diagnostic criteria using screening and

evaluation protocols for children, youth, and adolescents enrolled in SC Medicaid irrespective of their

foster care status.

These recommendations include:

Psychiatric diagnosis must be documented by applying specific diagnostic criteria using

screening and evaluation protocols for children, youth, and adolescents enrolled in SC

Medicaid irrespective of their foster care status.

A comprehensive mental health treatment plan that includes psychiatric services as

alternative or adjunct to pharmacological treatment and provisions of second opinion by

a qualified psychiatrist when appropriate should be developed by a psychiatrist in

consultation with the primary care provider.

Regular monitoring of psychotropic medication prescription patterns/use should be

conducted on a semi‐annual basis.

Information exchange and care coordination among providers, patients, and caregivers

should be considered critical elements of overall patient management plan.

Training and continuing education programs for providers should include mandatory mental

health components and updates related to changes in clinical practice guidelines related to

psychotropic medication use among children and adolescents.

Establish a psychotropic medication oversight advisory committee consisting of a wide range

of stakeholders to oversee psychotropic medication prescriptions for children and

adolescents enrolled in Medicaid with annual reports to state agencies.

56

It is evident from the study findings that nearly 17% of children enrolled in SC Medicaid who received a

psychotropic prescription in calendar year 2011 had not had listed psychiatric diagnoses. Nearly one in

two children who received antianxiety medications and one in five who received antidepressant

medication did not have a listed psychiatric diagnosis. Even for children who received antipsychotic

medications, nearly 5% did not have a psychiatric diagnosis. Lack of listed diagnoses limits the ability to

justify use of psychotropic medications among these children. These findings highlight the need of

documenting psychiatric diagnosis as outlined in the DSM‐IV before initiating psychotropic medications.

Initial mental health evaluation of children entering the foster care system should also include screening

for depression and substance use given the potential trauma experienced by these children. Regular

screenings and mental health evaluations should be a part of the protocol for all foster care children to

detect behavioral and emotional problems as well as adjustment issues at the earliest so that prompt and

effective management can be offered.

Recommendation 2:

A comprehensive mental health treatment plan that includes psychiatric services as alternative or

adjunct to pharmacological treatment and provisions of second opinion by a qualified psychiatrist

when appropriate should be developed by a psychiatrist in consultation with the primary care

provider.

After an initial evaluation and documented need for treatment, a comprehensive mental health

treatment plan should be developed by the psychiatrist in consultation with the child’s primary care

provider. It is recommended that non‐pharmacological psychiatric services such as counseling,

family/group therapy, or behavioral and cognitive therapy, etc., be tried first, prior to initiating

pharmacological treatment unless medications are absolutely indicated. Even for those children who

need medications to treat or control their mental health conditions, use of such psychiatric services as

adjunct to pharmacological treatments is recommended given that such combination improves mental

health outcomes and medication adherence. In our sample, nearly twice as many foster care children

received psychiatric services compared to non‐foster children. The results indicate differential treatment

for children in foster care compared to children not in foster care; however, it is unclear from the data

the reasons for the discrepancy in receipt of psychiatric services. This finding indicates a need for

standards about the appropriateness of adjunct therapy to be clearly communicated to providers. These

metrics, which may be endorsed by state agencies to improve implementation across providers and

practices,9, 10 can be continuously monitored using claims data to track changes in receipt of other

psychiatric services along with psychotropic medications.

Treatment protocols should be based on scientific evidence and up to date information related to

individual medication including its approved clinical use. As possible, established protocols should be

followed or adapted in formulating a specific treatment plan. The American Academy of Pediatrics (AAP)

Task Force on Mental Health20 and expanded scope ADHD clinical practice guidelines 21 are examples of

evidence‐based clinical protocols, which can be adopted to standardize the delivery of mental health

services to Medicaid children.

It is also recommended to include behavior modification plans, whenever necessary, to improve rates of

medication adherence. The findings from this analysis indicated that medication adherence was sub‐

57

optimal for antipsychotic medications when a stricter measure of adherence was used. Medication

adherence to psychotropic medications is critical in treatment outcomes since deviations from prescribed

dosage and frequency may have undesirable implications.

It is strongly recommended that this comprehensive plan be developed by the psychiatrist and the

primary care provider with mutual consultation to fit the specific needs of the individual child. It is also

recommended that an opinion by a second psychiatrist must be obtained before starting pharmacological

treatment for children aged 5 years or younger as well as for those children who need more than two

psychotropic medications concurrently.

Recommendation 3:

Regular monitoring of psychotropic medication prescription patterns/use and other psychiatric services

should be conducted on a semi‐annual basis.

After the initiation of pharmacological treatment, psychotropic prescriptions including antipsychotics

should be monitored regularly using Medicaid claims data on a semi‐annual basis. These semi‐annual

reports should include information of all the psychotropic medications prescribed to the patient

(medication names, dose, frequency, and duration), patient’s response to the treatment, side effects of

the prescribed medications if any, indication for changing or adding new medication(s), and utilization of

adjunct psychiatric services.

Such monitoring will allow officials to identify overuse of psychotropic prescriptions or underuse of

adjunct psychiatric services in children enrolled in Medicaid. It will also allow officials to identify

questionable prescription patterns such as antipsychotic prescriptions to children aged 5 years or

younger, prescription of four or more psychotropic medications in a single calendar year, and off‐label or

un‐indicated use of psychotropic medications. The study results indicated that more than 100 children 5

years or younger received antipsychotic prescriptions and that one out of every four of these children

received multi‐class treatment. Further, more than 10% of children receiving antipsychotic prescriptions

received four or more psychotropic medications. These findings raise serious concerns over potential

impact of multiple psychotropic medications among children. Similar to results found in other studies of

children receiving mental health care in South Carolina Medicaid, 11 children in this sample received more

atypical antipsychotics than conventional antipsychotic medications. While adherence rates for atypical

antipsychotics compared to conventional antipsychotic medications were mixed, careful monitoring of

prescribing patterns and adherence across patient populations is warranted.

Other questionable psychotropic prescriptions were also identified which are either not approved for use

in children or not recommended for children with mental health diagnoses. For example, the

antidepressant drug paroxetine (Paxil) is not approved for use in children less than 18 years for the

treatment of depression by the Food and Drug Administration (FDA). FDA issued warnings advising

clinicians of adverse effects in patients younger than 24 years of age, including hallucinations and suicide,

in 2003 and 2005, which resulted in lower rates of prescriptions among children and adolescents. 22‐24

Paroxetine was prescribed to children in our sample. Similarly, Provigil and Nuvigil, which are not

approved for use in children under age of 18 years are often used off‐label by pediatricians. 24 In our

study sample 26 children were prescribed Provigil‐Nuvigil and of these 14 children were under 18 years

58

of age. Tracking and reporting such prescriptions can lead to improvements in the quality of care by

limiting unapproved psychotropic medications prescribed to children. Medication management programs

and electronic prescribing can include reminders about FDA warnings and prevent questionable

psychotropic prescriptions to children.

Recommendation 4:

Information exchange and care coordination among providers, patients, and caregivers should be

considered critical elements of overall patient management plan.

Information exchange between providers, patients, and caregivers is critical in ensuring accurate

diagnosis, development of treatment and management plan and adherence to the prescribed plan which

will ultimately result in better patient outcomes. As mentioned earlier, patients and caregivers should be

informed about the clinical evaluation, diagnosis, and available treatment options. In addition, prior to

starting pharmacological treatment, the risks and benefits of psychotropic medications should be clearly

communicated with patients and their caregivers. Emphasis should also be placed on the need for

optimal medication adherence and reporting of side effects. The information exchange should be done in

a culturally and linguistically appropriate manner. This will help establish a trusting relationship with the

health care provider.

Care coordination is another critical element in optimizing treatment protocols and health outcomes.

Quality health care delivery to children receiving psychotropic medications, especially those in the foster

care system, requires coordination across providers, practices, and community service agencies. As

illustrated in Figure 4.1, careful coordination across these entities will enhance the delivery of care to

children in foster care. Continuous monitoring of referrals to behavioral health providers can improve the

information exchange across facilities. A formal mechanism of health information exchanges should be

established to promote care coordination across providers, practices, and caregivers caring for the

children in foster care system. In particular, electronic resources to store and communicate patient

information can improve delivery of care after hours, which may minimize costs associated with adverse

events for children receiving psychotropic medications. Another recommendation is to use a case

management approach to coordinate care among high risk children.

Use of technology such as short message system (SMS) or text message reminders about upcoming

doctor appointments or prescription refills can be considered to improve treatment adherence.

Additionally, information about mental health conditions, psychotropic medications, their potential

indications, contra‐indications, and side effects as well as responses to other frequently asked questions

can be uploaded on state agency websites. This information can be shared with patients and caregivers

to enhance patient education and support patient empowerment.

Recommendation 5:

Training and continuing education programs for providers should include mandatory mental health

components and updates on changes in clinical practice guidelines related to psychotropic medications

use among children and adolescents.

With evolving treatment for mental health conditions and new developments in criteria for childhood

mental health conditions and appropriate treatment options including psychotropic medications, it is

59

important that health care providers serving Medicaid children have up‐to‐date knowledge about

treatment recommendations and clinical guidelines in management of childhood psychiatric conditions.

Therefore, training and continuing education programs for providers must include mandatory mental

health components and information updates related to use of psychotropic medications among children

and adolescents.

The claims data are critically important in monitoring clinical measures and the quality of care delivered,

especially since the costs of observation are prohibitive and difficult to implement in population‐based

studies. However, the quality of data can be hampered by data entry errors on the practice level. Efforts

to train practice staff and providers about upcoming changes to CPT code list may prevent limitations in

the use of claims data and clinical data in the electronic health record system for other quality monitoring

reports. 25

Health care providers are also influential in improving adherence rates. In one study, clinician beliefs

about their ability to influence adherence to antipsychotic medications and educate patients using

evidence‐based strategies were found to be strong facilitators of medication adherence.26 However, in a

study of mental health case managers, nearly half of mental health nurses reported no training in

medication adherence strategies.27 Monitoring adherence using a standard metric will allow for an

evaluation of differences in adherence rates across providers and practices. Providers with lower

adherence rates should be targeted for additional training and education in adherence strategies.

Recommendation 6:

Establish a psychotropic medication oversight advisory committee consisting of a wide range of

stakeholders to oversee psychotropic medication prescriptions for children and adolescents enrolled in

Medicaid with annual reports to state agencies.

The oversight committee should include multiple stakeholders (clinicians, psychiatrists, pharmacists, case

managers, state agency staff, and caregivers) to oversee psychotropic medication prescriptions for

children, youth, and adolescents enrolled in Medicaid with annual reports to state agencies. Such

collaborative efforts to oversee psychotropic medication prescriptions will help improve quality of care

and ultimately health outcomes among Medicaid children with mental health needs.

Implications of Findings and Suggestions for Future Research

It is clear from the study findings that there is an urgent need to develop clinical guidelines and practice

protocols for prescribing psychotropic medications to children enrolled in SC Medicaid. Given that

multiple players at multiple levels influence health care services delivered to the most vulnerable

children in Medicaid (i.e. who need psychotropic medications for their mental health needs),

coordination of care becomes a critical element in care provision. Integration of health care and other

services including but not limited to primary care, psychiatric care (both pharmacological and adjunct

services), case management, social services, patient/caregiver education, and use of technology is

needed for optimal results. A patient‐centered medical home model can serve as the best conceptual

framework for providing quality care to children with mental health needs who are enrolled in Medicaid.

The common elements of a patient‐centered medical home which facilitate the effective delivery of

quality care are: (a) personal physician, (b) team practice, (c) coordinated care, (d) health information

60

technology and analytical tools, (e) expanded access to health providers, and (f) effective use of financial

services.28

Future avenues for research to inform public health practice include an analysis of prescribing patterns

for specific psychotropic drug classes, particularly ADHD and antidepressants among children using

Medicaid, poly‐pharmacy of psychotropic medications in children with chronic diseases such as diabetes,

and a qualitative investigation of the experiences of foster care parents and caregivers of children with

mental health diagnoses. In addition to the recommendations provided in this report, future studies can

identify other areas of improvement or reorganization of care delivery to children enrolled in Medicaid

with mental health diagnoses.

Study Limitations and Strengths

There are several limitations that need to be considered while interpreting the results. This report

described psychotropic prescription patterns among foster care and non‐foster care children enrolled in

SC Medicaid. This analysis was restricted to children who received at least one psychotropic medication

prescription in CY 2011 and so the results cannot be generalized to other state Medicaid populations. It is

also possible that the estimates of the prevalence of mental health disorders in children enrolled in SC

Medicaid may be underestimated due to incorrect or incomplete reporting. These errors can also occur in

entering clinical data into the electronic health record (EHR), which further underscores the importance

of training providers and support staff in coding.25 In context of the antipsychotic medication adherence

results, readers need to be aware that pharmacy claims data are limited in medical utilization studies

because the data do not reflect actual use or consumption of medications prescribed14 or the use of

pharmaceutical samples provided by providers.29 However, pharmacy claims data have been found to be

acceptable proxies for medical utilization and health outcomes research,30 particularly in patient

populations with only one source of pharmaceutical reimbursement, such as Medicaid recipients.31

Despite these limitations, study findings offer preliminary understanding of psychotropic prescription

patterns among vulnerable children enrolled in SC Medicaid. Recommendations for improving the quality

of mental health services to children enrolled in Medicaid offered in this report will likely assist other

states with poorer health rankings and similar population characteristics.

Conclusions

Children and adolescents in foster care are particularly vulnerable to mental health conditions. In an

examination of psychotropic medication prescribing patterns, differences in the delivery of mental health

treatment to children in foster care compared to other children were noted. Continued quality

improvement efforts to monitor outcomes in foster care children enrolled in Medicaid across providers

and populations will illuminate sources of these differences and inform strategies in how best to

reorganize delivery of quality mental health services to children in foster care.

61

TECHNICAL NOTES

The study used Medicaid claims data stored at the Institute for Families in Society (IFS) under contract to the SC Department of Health and Human Services. The sample included Medicaid beneficiaries aged 21 years or younger who received at least one prescription of psychotropic medication in calendar year 2011. All analyses were done using a de‐identified data set that included variables of interest extracted from recipient family file, A claims, D claims, and Z claims. All Medicaid claims [physician (A claims), pharmacy (D claims), and hospital (Z claims)] for each sampled beneficiary were extracted for calendar years 2009, 2010, and 2011. Dataset included unique identifier, age (as of December 31, 2011), sex, race, child status (as of December 31, 2011), drug class of psychotropic medication, Medicaid qualifying category, Medicaid assistant payment category, claim number and type, dates of service (begin and end date), site of service, provider type, diagnosis and procedure codes (ICD9, DRG, CPT, and HCPCS); clinical risk group (CRG) category, rural‐urban commuting area (RUCA) code, and unique indicator for social deprivation [Palmetto Small Area Deprivation Index (PSADI)]. For D claims, names of medications prescribed, national drug codes (NDC), date on which a particular prescription was dispensed, duration for which the medication was dispensed, and amount of medication supplied were also considered. This information was particularly useful in examining compliance or adherence to psychotropic drugs which was measured by two indicators [medication possession ratio (MPR) and proportion of days covered (PDC)] calculated from the original variables. For Z claims, days in hospital and DRG classification were considered. Multiple claims records for the same beneficiary are linked by using a distinct identification number (medinum).

Variables of interest and their definitions

The total Medicaid population in the eligible age group is comprised of 465,000 enrollees. Approximately 14% or 62,859 children comprised the study population. Of these, 4,012 (7%) were associated with a foster care placement. The Medicaid beneficiaries of interest were categorized based on their status into two broad groups: foster care children (who were under the state custody as of December 31, 2011) and non‐foster care children (who were not under the state custody, but enrolled in SC Medicaid as of December 31, 2011). Foster care children were further classified into one of the following categories: children who were adopted (adoption), children with emotional problems [those who were eligible for interagency system of care for emotionally disturbed children (ISCEDC)], children with complex medical conditions (MCC), and regular foster care.

Children in our sample were categorized into five age groups: less than 1 year, 1‐4 years, 5‐9 years, 10‐14 years, 15‐17 years, and 18‐21 years. Race was categorized into three categories: White/Caucasian, Black/African American, and Other. Nine levels of clinical risk group classification were examined for each child. The CRG status was dichotomized into mild or moderate (CRG<5) and severe (≥5). Area of residence was classified using the RUCA codes into urban, large rural, small rural, and isolated rural. In addition, we also classified children into three categories (urban high deprivation, rural high deprivation, and small‐to‐moderate deprivation) based on a special indicator for social deprivation (PSADI). The PSADI (similar to Townsend Index for Social Deprivation32) was created using special indicators specifically designed for South Carolina to indicate areas of social deprivation.

Nine drug classes for psychotropic medications were considered for the analysis. They included ADHD drugs, antianxiety drugs, anticonvulsants, antidepressants, antipsychotics, barbiturates, mood stabilizers, non‐barbiturate sedatives, and Provigil Nuvigil. These drug classes were extracted from the recipient family file. Since the frequency of children who received Provigil Nuvigil was less than 30 (n=26), they

62

were not included in further analysis. For the analysis specific to prescription antipsychotics, appropriate NDCs were flagged to obtain frequency of children receiving each specific antipsychotic medication.

Children were categorized into eight psychiatric diagnostic categories based on reported ICD‐9 codes. These diagnostic categories included:

1) Attention deficit and hyperactivity disorder [ADHD (ICD9=314)];

2) Adjustment disorders (ICD9=309.0 and 309.1);

3) Anxiety disorders (ICD9=300.00);

4) Disruptive behavior disorders [conduct disorder (312), oppositional defiant disorder (313.81)];

5) Mood disorders [bipolar disorder (ICD9=296), depressive disorder not classified elsewhere (ICD9=311), and dysthymic disorder (ICD9=300.4)];

6) Pervasive developmental disorders (ICD9=299.0‐299.8);

7) Psychotic disorders [schizophrenia (ICD 9 = 295 & 299.9), delusional disorders (ICD 9 = 297), and other non‐organic psychoses (ICD 9 = 298)]; and

8) Substance abuse disorders [alcohol dependence syndrome (303), drug dependence (304), non‐dependent drug abuse (305)].

Additionally, for the children who received antipsychotic medications, the records were flagged if they had the following ICD‐9 codes: 250 (diabetes), 783.1 or 278.0 (weight gain), 790.29 (hyperglycemia), 277.1 or 277.7 (metabolic syndrome), 577 (pancreatitis), 333.85 or 333.72 (neurological problems/movement disorder), 410, 411, 412, 413, 414, 426, 427, 428, 431, 432, 433, 434, 435, 436, 780.2 or 798 (cardiovascular conditions) to identify possible side effects of antipsychotic medications.

Outcome variables of interest included: 1) receipt of psychotropic medication from a particular drug class (coded yes or no for each of the drug classes mentioned above), 2) receipt of multi‐class treatment (coded yes or no depending on whether the beneficiary has received psychotropic prescriptions from two or more drug classes), and 3) receipt of psychiatric services other than pharmacologic treatment [coded as yes or no using the following specific CPT codes (Please refer to Appendix D for description of codes) S8180, S8181, S8184, S8185, S8186, H2029, 90804, 90806, 90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826, 90828, 90849, 90853, 90857, 90870, 90875, 90876, 90880, 90901, 96100, 96151, 96152, 96153, 96154, 96155, 90846, 90847, 99241]. Independent variables included age, sex, race, child status, and psychiatric diagnosis (coded yes or no) whereas control variables included CRG category, RUCA codes, and PSADI.

Descriptive statistics were conducted to describe characteristics of children (in each status category) who received psychotropic medication in CY 2011. Each outcome variable of interest is examined by age group, sex, race, child status, and psychiatric diagnosis. Additionally, among those who received antipsychotic prescription, proportion of children with ICD‐9 diagnosis suggesting potential side‐effects of antipsychotic medication is also examined. Chi‐square tests were conducted to examine group differences for each outcome variable. Group differences were examined between regular foster and non‐foster children, regular foster and ISCEDC children, and regular foster and adoption children.

63

ACKNOWLEDGEMENTS

We are grateful for the assistance of Teresa Payne, MSPH, Senior Research Associate, and Tammy Harris, MSPH, Research Associate, of the Division of Policy and Research on Medicaid and Medicare (PRMM), Institute for Families in Society. Under the direction of Dr. Ana Lòpez‐De Fede, Ms. Payne and Ms. Harris compiled the relevant Medicaid data files of interest for use in the study. We are grateful for their data management assistance.

64

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APPENDIX

APPENDIX A: Psychotropic Drug Classes Tables

APPENDIX B: Psychotropic Medications – List of Brand Names

APPENDIX C: Psychiatric Diagnoses Listed for Children in the Sample

APPENDIC D: Description of CPT Codes

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APPENDIX A: Findings by Psychotropic Drug Classes

A.1: ADHD Medications

A.2: Antidepressants A.3: Anticonvulsants A.4: Antianxiety Medications A.5: Barbiturate Sedatives A.6: Mood Stabilizers A.7: Non‐barbiturate Sedatives

69

Table A1. Selected Characteristics of SC Medicaid Children Who Received ADHD Prescriptions in CY 2011


n (%) Non‐Foster (n=6,243)

n (%) Reg. Foster (n=756)

n (%) ISCEDC (n=677)

n (%) Adoption (n=1,911)

n (%)

Sex

Male 32,018 (69.60) 29,948 (70.21)a 473 (62.57)a 429 (63.37) 1,166 (61.02) Female 13,982 (30.40) 12,704 (29.79)a 283 (37.43)a 248 (36.63) 745 (38.98)

Age [Mean (SD)] [11.12(0.02)] [11.05 (.02)] [11.49 (0.15)] [13.23 (0.13)] [11.89 (0.08)] < 1 ‐‐‐ ‐‐‐ 0 (0.00) 0 (0.00) 0 (0.00) 1‐4 486 (1.06) 449 (1.05) 13 (1.72) ‐‐‐ 20 (1.05) 5‐9 16,534 (35.94) 15,639 (36.67) 260 (34.39)b 107 (15.81)b 527 (27.58) 10‐14 19,931 (43.33) 18,496 (43.36) 280 (37.04)b 288 (42.54)b 867 (45.37) 15‐17 6,772 (14.72) 6,052 (14.19) 134 (17.72)b 221 (32.64)b 362 (18.94) 18‐21 2,276 (4.95) 2,015 (4.72) 69 (9.13)b 57 (8.42)b 135 (7.06)

Race White 24,559 (53.39) 22,953 (53.81)a 369 (48.81)a, b, c 285 (42.10)b 951 (49.76)c African‐American 15,031 (32.68) 13,638 (31.98)a 343 (45.37)a, b, c 267 (39.44)b 781 (40.87) c Other 6,410 (13.93) 6,061 (14.21)a 44 (5.82)a, b, c 125 (18.46)b 179 (9.37) c

Status Non‐foster care 42,652 (92.72) 42,652 (100.00) N/A N/A N/A All foster care 3,348 (7.28) Adoption† 1,911 (4.15) N/A N/A N/A 1,911 (100.00) ISCEDC† 677 (1.47) N/A N/A 677 (100.00) N/A MCC† ‐‐‐ N/A N/A N/A N/A Regular foster† 756(1.64) N/A 756 (100.00) N/A N/A

Clinical Risk Group Healthy/moderate 22,694 (49.33) 21,447 (50.28)a 317 (41.93)a, b 75 (11.08)b 855 (44.74) Severe/catastrophic 23,306 (50.67) 21,205 (49.72)a 439 (58.07)a, b 602 (88.92)b 1,056 (55.26)

70





n (%) Adoption (n=1,911)

n (%)

Rurality‡

Urban 30,887 (67.15) 28,444 (66.69)a 552 (73.02)a 521 (76.96) 1366 (71.48) Large Rural 10,290 (22.37) 9,739 (22.83) 130 (17.20) 107 (15.81) 314 (16.43) Small Rural 3,107 (6.75) 2,862 (6.71) 54 (7.14) 39 (5.76) 152 (7.95) Isolated Rural 1,697 (3.69) 1,591 (3.73) 18 (2.38) 10 (1.48) 78 (4.08)

Deprivation Index PSADI‡ Low‐moderate 37,885 (82.36) 35,292 (82.74)a 505 (66.80)a, c 477 (70.46) 1,607 (84.09)c High Rural 4,342 (9.44) 4,000 (9.38)a 90 (11.90) a, c 56 (8.27) 196 (10.26)c High Urban 3,754 (8.16) 3,344 (7.84)a 159 (21.03) a, c 144 (21.27) 107 (5.60)c

Psychiatric diagnosis 43,273 (94.07) 40,074 (93.96)a 738 (97.62)a, b, c 675 (99.70)b 1,782 (93.25)c

Psychiatric services 17,781 (38.65) 15,707 (36.83)a 543 (71.83)a, b, c 638 (94.24)b 891 (46.62)c

Multi‐class treatment 11,028 (23.97) 9,726 (22.80)a 239 (31.61)a, b 473 (69.87)b 590 (30.87)

Note: Italicized estimated percentages are based on fewer than 30 observations and thus are statistically unreliable, ‐‐‐ Cell sizes less than 6 are suppressed. † Adoption, ISCEDC, MCC, and Regular Foster are subcategories of foster care and MCC is not included as a separate column due to

extremely small sample size. ‡ Columns may not total 100% due to rounding and missing values. a Statistically significant difference between Regular Foster Care and Non‐Foster Care children. b Statistically significant difference between Regular Foster Care and ISCEDC children. c Statistically significant difference between Regular Foster Care and Adoption children.

71

Table A2. Selected Characteristics of SC Medicaid Children Who Received Antidepressant Prescriptions in CY2011

Characteristic

Total (n=14,909) n (%)





Sex

Male 6,847 (45.93) 6,218 (45.65) 138 (46.00) 212 (47.64) 273 (51.32) Female 8,062 (54.07) 7,404 (54.35) 162 (54.00) 233 (52.36) 259 (48.68)

Age [Mean (SD)] [14.61 (.03)] [14.65 (.03)] [14.53 (0.24)] [14.61 (0.13)] [13.79 (0.16)]

< 1 ‐‐‐ ‐‐‐ 0 (0.00) 0 (0.00) 0 (0.00)

1‐4 108 (0.72) 99 (0.73) ‐‐‐ 0 (0.00) ‐‐‐

5‐9 1,743 (11.69) 1,606 (11.79) 36 (12.00)b, c 27 (6.07)b 73 (13.72)c

10‐14 4,688 (31.44) 4,225 (31.02) 83 (27.67)b, c 159 (35.73)b 218 (40.98)c

15‐17 4,422 (29.66) 3,971 (29.15) 93 (31.00)b, c 205 (46.07)b 149 (28.01)c

18‐21 3,948 (26.48) 3,721 (27.32) 83 (27.67)b, c 54 (12.13)b 89 (16.73)c

Race

White 9,222 (61.86) 8,567 (62.89)a 163 (54.33)a, b 199 (44.72)b 291 (54.70)

African‐American 3,379 (22.66) 2,908 (21.35)a 118 (39.33)a, b 168 (37.75)b 181 (34.02)

Other 2,308 (15.48) 2,147 (15.76)a 19 (6.33)a, b 78 (17.53)b 60 (11.28)

Status

Non‐foster care 13,622 (91.37) 13,622 (100.00) N/A N/A N/A

All foster care 1,287 (8.63) N/A N/A N/A N/A

Adoption† 532 (3.57) N/A N/A N/A 532 (100.00)

ISCEDC† 445 (2.98) N/A N/A 445 (100.00) N/A

MCC† 10 (0.07) N/A N/A N/A N/A

Regular foster† 300 (2.01) N/A 300 (100.00) N/A N/A

Clinical Risk Group

Healthy/moderate 4,761 (31.93) 4,542 (33.34)a 74 (24.67)a, b 25 (5.62)b 120 (22.56)

Severe/catastrophic 10,148 (68.07) 9,080 (66.66)a 226 (75.33)a, b 420 (94.38)b 412 (77.44)

72

Characteristic

Total (n=14,909) n (%)





Rurality‡

Urban 10,487 (70.34) 9,519 (69.88) 227 (75.67) 335 (75.28) 399 (75.00)

Large Rural 3,008 (20.18) 2,799 (20.55) 52 (17.33) 71 (15.96) 83 (15.60)

Small Rural 882 (5.92) 803 (5.89) 15 (5.00) 31 (6.97) 33 (6.20)

Isolated Rural 521 (3.49) 492 (3.61) ‐‐‐ 8 (1.80) 16 (3.01)


Low‐moderate 12,542 (84.12) 11,583 (85.03)a 200 (66.67)a, c 304 (68.31) 449 (84.40)c

High Rural 1,241 (8.32) 1,120 (8.22)a 33 (11.00)a, c 39 (8.76) 46 (8.65)c

High Urban 1,115 (7.48) 910 (6.68)a 66 (22.00)a, c 102 (22.92) 36 (6.77)c

Psychiatric diagnosis 21,317 (82.61) 11,096 (81.46)a 283 (94.33)a, b 444 (99.78)b 486 (91.35)Psychiatric services 7,888 (52.91) 6,883 (50.53)a 247 (82.33)a, b, c 412 (92.58)b 343 (64.47)c

Multi‐class treatment 9,463 (63.47) 8,452 (62.05)a 217 (72.33)a, b, c 368 (82.70)b 426 (80.08)c

Note: Italicized estimated percentages are based on fewer than 30 observations and thus are statistically unreliable. ‐‐‐ Cell sizes less than 6 are suppressed. † Adoption, ISCEDC, MCC, and Regular Foster are subcategories of foster care and MCC is not included as a separate column due to


73

Table A3. Selected Characteristics of SC Medicaid Children Who Received Anticonvulsant Prescriptions in CY 2011





n (%) Adoption (n=287)

n (%)

Sex

Male 4,860 (53.37) 4,493 (53.18) 60 (54.05) 132 (58.67) 154 (53.66) Female 4,247 (46.63) 3,956 (46.82) 51 (45.95) 93 (41.33) 133 (46.34)

Age [Mean (SD)] [12.69(0.06)] [12.65 (.06)] [12.99 (0.59)] [14.36 (0.22)] [12.47 (0.28)] < 1 39 (0.43) 36 (0.43) ‐‐ 0 (0.00) 0 (0.00) 1‐4 854 (9.38) 813 (9.62) 18 (16.22) ‐‐‐ 17 (5.92) 5‐9 1,643 (18.04) 1,543 (18.26) 12 (10.81)b, c 22 (9.78)b 64 (22.30)c

10‐14 2,610 (28.66) 2,419 (28.63) 19 (17.12)b, c 66 (29.33)b 94 (32.75)c

15‐17 2,018 (22.16) 1,798 (21.28) 28 (25.23)b, c 112 (49.78)b 71 (24.74)c

18‐21 1,943 (21.34) 1,840 (21.78) 33 (29.73)b, c 22 (9.78)b 41 (14.29)c

Race White 4,148 (45.55) 3,858 (45.66)a 59 (53.15)a, b, c 77 (34.22)b 150 (52.26)c

African‐American 2,265 (24.87) 2,028 (24.00)a 46 (41.44)a, b, c 90 (40.00)b 92 (32.06)c

Other 2,694 (29.58) 2,563 (30.33)a 6 (5.41)a, b, c 58 (25.78)b 45 (15.68)c

Status Non‐foster care 8,449 (92.77) 8,449 (100.00) N/A N/A N/A All foster care 658 (7.23) N/A N/A N/A N/A Adoption† 287 (3.15) N/A N/A N/A 287 ISCEDC† 225 (2.47) N/A N/A 225 (100.00) N/A MCC† 35 (0.38) N/A N/A N/A N/A Regular foster† 111 (1.22) N/A 111 (100.00) N/A N/A

Clinical Risk Group Healthy/moderate 1,285 (14.11) 1,241 (14.69) 14 (12.61) ‐‐‐ 26 (9.06) Severe/catastrophic 7,822 (85.89) 7,208 (85.31) 97 (87.39)b 221 (98.22)b 261 (90.94)

74





n (%) Adoption (n=287)

n (%)

Rurality‡

Urban 6,205 (68.13) 5,735 (67.82) 82 (73.87) 167 (74.22) 201 (70.03) Large Rural 1,921 (21.09) 1,795 (21.25) 24 (21.62) 43 (19.11) 50 (17.42) Small Rural 631 (6.93) 598 (7.08) ‐‐‐ 9 (4.00) 20 (6.97) Isolated Rural 346 (3.80) 323 (3.82) ‐‐‐ 6 (2.67) 15 (5.23)


Low‐moderate 7,412 (81.39) 6,908 (81.67)a 83 (74.77)a, c 158 (70.22) 232 (80.84)c

High Rural 938 (10.30) 870 (10.30)a 8 (7.21) a, c 23 (10.22) 36 (12.54)c

High Urban 753 (8.27) 668 (7.91)a 20 (18.02) a, c 44 (19.56) 18 (6.27)c

Psychiatric diagnosis 5,456 (59.91) 4,917 (58.20)a 89 (80.18)a, b 222 (98.67)b 213 (74.22)

Psychiatric services 3,286 (36.08) 2,879 (34.08)a 72 (64.86)a, b, c 193 (85.78)b 136 (47.39)c

Multi‐class treatment 4,748 (56.20)a 82 (73.87)a, b 208 (92.44)b 216 (75.26)

Note: Italicized estimated percentages are based on fewer than 30 observations and thus are statistically unreliable. ‐‐‐ Cell sizes less than 6 are suppressed. † Adoption, ISCEDC, MCC, and regular foster are subcategories of foster care and MCC is not included as a separate column due to


75

Table A4. Selected Characteristics of SC Medicaid Children Who Received Antianxiety Prescriptions in CY 2011

Characteristic Total (n=4,190) All Foster Care (n=153) Non‐Foster (n=4,037)

p value* n % n % n %

Sex

0.18

Male 1,754 41.86 72 47.06 1,682 41.66

Female 2,436 58.14 81 52.94 2,355 58.34

Age [Mean (SD)] 14.09 (0.48) 14.41 (0.34) 13.75 (.08) 0.002

< 1 10 0.24 ‐‐‐ ‐‐‐ 10 0.25

1‐4 222 5.30 ‐‐‐ ‐‐‐ 221 5.47

5‐9 834 19.90 23 15.03 811 20.09

10‐14 825 19.69 47 30.72 778 19.27

15‐17 1,004 23.96 40 26.14 964 23.88

18‐21 1,205 30.91 42 27.45 1,253 31.04

Race 0.03

White 2,162 51.60 71 46.41 2,091 51.80

African‐American 1,247 29.76 60 39.22 1,187 29.40

Other 781 18.64 22 14.38 759 18.80

Status

Non‐foster Care 4,037 96.35 N/A N/A 4,037 100.00

Foster Care 153 3.65 153 100.00 N/A N/A

Adoption 79 1.89 79 51.63 N/A N/A

ISCEDC 31 0.74 31 20.26 N/A N/A

MCC 6 0.14 6 3.92 N/A N/A

Regular foster 37 0.88 37 24.18 N/A N/A

76

Characteristic Total (n=4,190) All Foster Care (n=153) Non‐Foster (n=4,037)


Clinical Risk Group <.0001

Healthy/moderate 1,920 45.82 34 22.22 1,886 46.72

Severe/catastrophic 2,270 54.18 119 77.78 2,151 53.28

Rurality† <.0001

Urban 2,884 68.83 126 82.35 2,758 68.32

Large Rural 771 18.40 18 11.76 753 18.65

Small Rural 365 8.71 ‐‐‐ ‐‐‐ 360 8.92

Isolated Rural 168 4.01 ‐‐‐ ‐‐‐ 165 4.09

Deprivation Index† 0.001

Low‐moderate 3,360 80.19 129 84.31 3,231 80.03

High Rural 535 12.77 12 7.84 523 12.96

High Urban 293 6.99 11 7.19 282 6.99

Psychiatric diagnosis 2,150 51.31 121 79.08 2,029 50.26 <.0001

Psychiatric services 1,024 24.44 82 53.59 936 23.19 <.0001

Note: Italicized estimated percentages are based on fewer than 30 observations and thus are statistically unreliable. ‐‐‐ Cell sizes less than 6 are suppressed.

† Adoption, ISCEDC, MCC, and regular foster are subcategories of foster care and are grouped together as All Foster Care due to small sample sizes. ‡ Columns may not total 100% due to rounding and missing values. * The p‐value indicates statistically significant differences between All Foster Care and Non‐Foster Care children on selected variables.

77

Table A5. Selected Characteristics of SC Medicaid Children Who Received Barbiturate Sedative Prescriptions in CY 2011

Characteristic Total (n=249) All Foster Care (n=23) Non‐Foster (n=226)


Sex

0.97

Male 120 48.19 11 47.83 109 48.23

Female 129 51.81 12 52.17 117 51.77

Age [Mean (SD)] [6.54 (.42)] [7.04 (1.6)] [6.49 (.44)] 0.43

< 1 49 19.68 ‐‐‐ ‐‐‐ 44 19.47

1‐4 86 34.54 8 78 34.51

5‐9 30 12.05 ‐‐‐ ‐‐‐ 28 12.39

10‐14 40 16.06 ‐‐‐ ‐‐‐ 39 17.26

15‐17 23 9.24 ‐‐‐ ‐‐‐ 19 8.41

18‐21 21 8.43 ‐‐‐ ‐‐‐ 18 7.96

Race <.0001

White 69 27.71 7 30.43 62 27.43

African American 52 20.88 9 39.13 43 19.03

Other 128 51.41 7 30.43 121 53.54

Status †

Non‐foster care 226 90.76 N/A N/A 226 100.00

Foster care 23 9.24 23 100.00 N/A N/A

Adoption ‐‐‐ ‐‐‐ ‐‐‐ ‐‐‐ N/A N/A

ISCEDC 0 0.00 0 0.00 N/A N/A

MCC 9 3.61 9 39.13 N/A N/A


78



Clinical Risk Group

0.77

Healthy/moderate 26 10.44 ‐‐‐ ‐‐‐ 24 10.62

Severe/catastrophic 223 89.56 21 91.30 202 90.58

Rurality 0.09

Urban 153 61.45 15 65.22 138 61.06

Large Rural 53 21.29 8 34.78 45 19.91

Small Rural 31 12.45 0 0.00 31 13.72

Isolated Rural 12 4.82 0 0.00 12 5.31

Deprivation Index 0.29

Low‐moderate 167 67.07 15 65.22 152 67.26

High Rural 51 20.48 ‐‐‐ ‐‐‐ 48 21.24

High Urban 31 12.45 ‐‐‐ ‐‐‐ 26 11.50

Psychiatric diagnosis 38 15.26 ‐‐‐ ‐‐‐ 36 15.93 0.36

Psychiatric services 14 5.62 ‐‐‐ ‐‐‐ 11 4.87 0.10

Note: Italicized estimated percentages are based on fewer than 30 observations and thus are statistically unreliable. ‐‐‐ Cell sizes less than 6 are suppressed. † Adoption, ISCEDC, MCC, and regular foster are subcategories of foster care and are grouped together as All Foster Care due to small sample sizes. * The p value indicates statistically significant differences between All Foster Care and Non‐Foster Care children on selected variables.

79

Table A6. Selected Characteristics of SC Medicaid Children Who Received Mood Stabilizer Prescriptions in CY 2011



Sex

<.0001

Male 180 59.60 26 52.00 154 61.11

Female 122 40.40 24 48.00 98 38.89

Age [Mean (SD)] [15.95(.19)] [15.18(.37)] [16.10 (.21)] 0.08

< 1 ‐‐‐ ‐‐‐ ‐‐‐ ‐‐‐ ‐‐‐ ‐‐‐

1‐4 ‐‐‐ ‐‐‐ ‐‐‐ ‐‐‐ ‐‐‐ ‐‐‐

5‐9 6 1.99 ‐‐‐ ‐‐‐ ‐‐‐ ‐‐‐

10‐14 86 28.48 17 34.00 69 27.38

15‐17 110 36.42 24 48.00 86 34.13

18‐21 99 32.78 8 16.00 91 36.11

Race <.0001

White 150 49.67 18 36.00 132 52.38

African‐American 57 18.87 21 42.00 36 14.29

Other 95 31.46 11 22.00 84 33.33

Status †

Non‐foster care 252 83.44 N/A N/A 252 100.00

Foster care 50 16.56 50 100.00 N/A N/A

Adoption 16 5.30 16 32.00 N/A N/A

ISCEDC 28 9.27 28 56.00 N/A N/A

MCC ‐‐‐ ‐‐‐ ‐‐‐ ‐‐‐ N/A N/A


80



Clinical Risk Group

0.53

Healthy/moderate ‐‐‐ ‐‐‐ ‐‐‐ ‐‐‐ ‐‐‐ ‐‐‐

Severe/catastrophic 300 99.34 50 100.00 250 99.21

Rurality 0.37

Urban 222 73.51 39 78.00 183 72.62

Large Rural 55 18.21 7 14.00 48 19.05

Small Rural 15 4.97 ‐‐‐ ‐‐‐ 14 5.56

Isolated Rural 10 3.31 ‐‐‐ ‐‐‐ 7 2.78

Deprivation Index 0.03

Low‐moderate 246 81.46 35 70.00 211 83.87

High Rural 26 8.61 ‐‐‐ ‐‐‐ 21 8.33

High Urban 30 9.93 10 20.00 20 7.94

Psychiatric diagnosis 294 97.35 49 98.00 245 97.22 0.75

Psychiatric services 218 72.19 38 76.00 180 71.43 0.51

Note: Italicized estimated percentages are based on fewer than 30 observations and thus are statistically unreliable. ‐‐‐ Cell sizes less than 6 are suppressed.

† Adoption, ISCEDC, MCC, and regular foster are subcategories of foster care and are grouped together as All Foster Care due to small sample sizes. * The p value indicates statistically significant differences between All Foster Care and Non‐Foster Care children on selected variables.

81

Table A7. Selected Characteristics of SC Medicaid Children Who Received Non‐Barbiturate Sedative Prescriptions in CY 2011

Characteristic Total (n=1,423) Foster Care (n=62) Non‐Foster (n=1,361)

p value*n % n % n %

Sex

0.18 Male 616 43.29 32 51.61 584 42.91 Female 807 56.71 30 48.39 777 57.09

Age [Mean (SD)] [12.99(0.18)] [13.71(0.77)] [12.95 (0.18)] 0.22 < 1 9 0.63 ‐‐‐ ‐‐‐ 8 0.59 1‐4 278 19.54 8 12.90 270 19.84 5‐9 203 14.27 7 11.29 196 14.40 10‐14 136 9.56 8 12.90 128 9.40 15‐17 239 16.80 16 25.81 223 16.39 18‐21 558 39.21 22 35.48 536 39.38

Race 0.12 White 740 52.00 33 52.23 707 51.95 African‐American 390 27.41 22 35.48 368 27.04 Other 293 20.59 7 11.29 286 21.01

Status† Non‐foster care 1,361 95.64 N/A N/A 1,361 100.00 Foster care 62 4.36 62 100.00 N/A N/A Adoption 20 1.41 20 33.26 N/A N/A ISCEDC 14 0.98 14 22.58 N/A N/A MCC 3 0.21 ‐‐‐ ‐‐‐ N/A N/A Regular foster 25 1.76 25 40.32 N/A N/A

Clinical Risk Group 0.0009Healthy/moderate 563 39.56 12 19.35 551 40.48 Severe/catastrophic 860 60.44 50 80.65 810 59.52

82

Note: Italicized estimated percentages are based on fewer than 30 observations and thus are statistically unreliable. ‐‐‐ Cell sizes less than 6 are suppressed. † Adoption, ISCEDC, MCC, and regular foster are subcategories of foster care and are grouped together as All Foster Care due to small sample sizes. ‡ Columns may not total 100% due to rounding and missing values. * The p value indicates statistically significant differences between All Foster Care and Non‐Foster Care children on selected variables.

Rurality‡ 0.0001 Urban 937 65.85 42 67.74 895 65.76 Large Rural 309 21.71 16 25.81 293 21.53 Small Rural 112 7.87 ‐‐‐ ‐‐‐ 109 8.01 Isolated Rural 64 4.50 ‐‐‐ ‐‐‐ 63 4.63

Deprivation Index‡ 0.16 Low‐moderate 1,163 81.73 44 70.97 1,119 82.22 High Rural 176 12.37 12 19.35 164 12.05 High Urban 83 5.83 6 9.68 77 5.66

Psychiatric diagnosis 697 48.98 44 70.97 653 47.98 0.0004

Psychiatric services 393 27.62 24 61.29 369 27.11 0.05

83

APPENDIX B. Psychotropic Medications – List of Brand Names

APPENDIX B.1. Antipsychotic Medications

ABILIFY

CHLORPROMAZINE

CLOZAPINE

CLOZARIL

DROPERIDOL

FANAPT

FAZACLO

FLUPHENAZINE

GEODON

HALDOL

HALOPERIDOL

INAPSINE

INVEGA

LATUDA

LOXAPINE

LOXITANE

MOBAN

NAVANE

OLANZAPINE

ORAP

PERPHENAZINE

RISPERDAL

RISPERIDONE

SAPHRIS

SEROQUEL

THIORIDAZINE

THIOTHIXENE

TRIFLUOPERAZINE

ZYPREXA

ZYPREXA RELPREVV

ZYPREXA ZYDIS

APPENDIX B.2. ADHD Medications

ADDERALL

AMPHETAMINE SALT COMBO

CONCERTA

DAYTRANA

DESOXYN

DEXEDRINE

DEXMETHYLPHENIDATE HCL

DEXTROAMPHETAMINE SULFATE

DEXTROAMPHETAMINE‐AMPHETAMINE

DEXTROSTAT

FOCALIN

INTUNIV

KAPVAY

LIQUADD

METADATE

METHAMPHETAMINE

METHYLIN

PROCENTRA

RITALIN

STRATTERA

VYVANSE

84

APPENDIX B.3. Antidepressant Medications

AMITRIPTYLINE PAMELOR

AMITRIPTYLINE‐CHLORDIAZEPOXIDE PARNATE

AMITRIPTYLINE‐PERPHENAZINE PAROXETINE

AMOXAPINE PAXIL

ANAFRANIL PERPHENAZINE‐AMITRIPTYLINE

APLENZIN PEXEVA

APPBUTAMONE PHENELZINE SULFATE

BUDEPRION PRISTIQ

BUPROPION PROTRIPTYLINE HCL

CELEXA PROZAC

CHLORDIAZEPOXIDE‐AMITRIPTYLINE RAPIFLUX

CITALOPRAM REMERON

CYMBALTA SARAFEM

DESIPRAMINE HCL SELFEMRA

DESYREL SENTROXATINE

DOXEPIN HCL SERTRALINE HCL

EFFEXOR SERZONE

EMSAM SINEQUAN

FLUOXETINE ST. JOHN'S WORT

GABOXETINE SURMONTIL

IMIPRAMINE SYMBYAX

LEXAPRO TOFRANIL

LIMBITROL TRANYLCYPROMINE SULFATE

LUVOX TRAZAMINE

MAPROTILINE TRAZODONE HCL

MARPLAN TRIMIPRAMINE MALEATE

MIRTAZAPINE VANATRIP

MOVANA VENLAFAXINE

NARDIL VIIBRYD

NEFAZODONE VIVACTIL

NORPRAMIN WELLBUTRIN

NORTRIPTYLINE ZOLOFT

OLEPTRO

85

APPENDIX B.4. Anticonvulsant Medications

BANZEL LYRICA

CARBAMAZEPINE MEBARAL

CARBATROL MEPHOBARBITAL

CELONTIN MYSOLINE

CEREBYX NEURONTIN

CLONAZEPAM ONFI

DEPACON OXCARBAZEPINE

DEPAKENE PEGANONE

DIASTAT PHENYTEK

DIAZEPAM PHENYTOIN

DILANTIN PRIMIDONE

DIVALPROEX SODIUM SABRIL

EPITOL STAVZOR

ETHOSUXIMIDE TEGRETOL

FANATREX THERAPENTIN

FELBAMATE TOPAMAX

FELBATOL TOPIRAGEN

FOSPHENYTOIN SODIUM TOPIRAMATE

GABAPENTIN TRILEPTAL

GABARONE VALPROATE SODIUM

GABITRIL VALPROIC ACID

KEPPRA VIMPAT

KLONOPIN ZARONTIN

LAMICTAL ZONEGRAN

LAMOTRIGINE ZONISAMIDE

LEVETIRACETAM

86

APPENDIX B.5. Antianxiety Medications

APPENDIX B.6.

Barbiturate Sedative Medications

APPENDIX B.7.

Mood Stabilizer Medications

EQUETRO

ESKALITH CR

LITHIUM

LITHOBID

APPENDIX B.8.

Non‐Barbiturate Medications

ALCOHOL IN DEXTROSE PROSOM

ALCOHOL,DEHYDRATED REST SIMPLY

ALLERGY RELIEF RESTFULLY SLEEP

AMBIEN RESTORIL

AQUACHLORAL ROZEREM

ATIVAN SERENITAS

CHLORAL HYDRATE SILENOR

COMPOZ SIMPLY SLEEP

DALMANE SLEEP AID

DIPHENHYDRAMINE HCL SLEEP II

DORAL SLEEP TABLET

EDLUAR SLEEP‐ETTES D

ESTAZOLAM SLEEP‐EZE 3

ETHANOL SLEEPGELS

FAST SLEEP SOMINEX

FLURAZEPAM HCL SOMNOTE

HALCION SONATA

HCA SLEEP‐EX STRAZEPAM

INSOMNIA NO.40 TEMAZEPAM

LORAZEPAM TOPROPHAN

L‐TRYPTOPHAN TRANQUIL‐EZE

LUNESTA TRIAZOLAM

LYDIA PINKHAM HERBAL ULTRA SLEEP

MEDI‐SLEEP UNISOM

MELATONIN WAL‐SOM

MIDAZOLAM HCL XYREM

NIGHTTIME SLEEP AID ZALEPLON

NYTOL ZOLPIDEM TARTRATE

PRECEDEX ZOLPIMIST

ALPRAZOLAM

ATIVAN

BUSPAR

BUSPRION

CHLORDIASEPOXIDE

CLORAZEPATE

DIAZEPAM

GABAZOLAMINE

LIBRIUM

LORAZEPAM

MEPROBAMATE

MILTOWN

NIRAVAM

OXAZEPAM

PAXIPAM

SERAX

TRANXENE

VALIUM

VANSPAR

XANAX

AMYTAL SODIUM

BUTISOL SODIUM

LUMINAL SODIUM

NEMBUTAL SODIUM

PENTOBARBITAL

SECONAL SODIUM

87

APPENDIX C. Psychiatric Diagnoses for Children in Study

Table C1. Reported Psychiatric Diagnoses Among SC Medicaid Children Receiving Psychotropic Medication Prescriptions

Diagnosis

Total (N=62,859) All Foster Care (N=4,202)

Non‐foster Care (N=58,657)

n % n % n %

ADHD 43,599 69.36 3,337 79.41 40,262 68.64

Adjustment disorder 7,058 11.23 1,417 33.72 5,641 9.62

Anxiety disorder 4,988 7.94 401 9.54 4,587 7.82

Disruptive behavior disorders† 10,709 17.04 1,404 33.41 9,305 15.86

Conduct disorder 7,489 11.91 912 21.7 6,577 11.21

Oppositional defiance disorder

5,001 7.96 866 20.61 4,135 7.05

Mood disorders† 9,987 15.89 1,343 31.96 8,644 14.74

Bipolar disorder 6,646 10.57 946 22.51 5,700 9.72

Depression not classified elsewhere

5,113 8.13 777 18.49 4,336 7.39

Dysthymia 796 1.27 70 1.67 726 1.24

Pervasive developmental disorder

3,169 5.04 225 5.35 2,944 5.02

Psychotic disorders† 884 1.41 110 2.62 774 1.32

Delusion 46 .07 6 .14 40 .07

Schizophrenia 0 0 0 0 0 0

Other psychotic disorders 864 1.37 105 2.50 759 1.29

Substance abuse disorders† 1,559 2.48 164 3.90 1,395 2.38

Alcohol dependence 108 .17 10 .24 98 .17

Drug dependence 626 1.00 72 1.71 554 .94

Non‐dependent drug abuse 1,146 1.82 116 2.76 1,030 1.76

Note: All Foster Care category includes children in regular foster, ISCEDC, adoption, and MCC categories. † Overall frequency is less than the individually added frequencies of sub‐categories due to overlapping diagnoses (An individual may have more than one diagnosis listed in the claims data).

88

APPENDIX D. Description of CPT Codes

Table D1. Description of CPT codes used to identify psychiatric services

CPT Code Description

S8180 School‐based psychological testing and evaluation

S8181 Annual/transfer review

S8184 School psychosocial assessment

S8185 School individual psychosocial therapy

S8186 School group psychosocial therapy

H2029 Sexual offender treatment services, per diem

90804 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20‐30 minutes face‐to‐face with the patient

90806 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, approximately 45‐50 minutes face‐to‐face with the patient


90810 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanism of non‐verbal communication approximately 20‐30 minutes face‐to‐face with the patient



90816 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital, or residential care facility, approximately 20‐30 minutes face‐to‐face with the patient





90828 Individual psychotherapy, interactive, using play equipment, physical devices, language

89

CPT Code Description

interpreter, or other mechanism of non‐verbal communication approximately 75‐80 minutes face‐to‐face with the patient

90846 Family psychotherapy without the patient present

90847 Family psychotherapy (conjoint psychotherapy) with the patient present

90849 Multiple‐family group psychotherapy

90853 Group psychotherapy (other than of a multiple‐family group)

90857 Interactive group psychotherapy

90870 Electroconvulsive therapy (includes necessary monitoring)

90875 Individual psychophysiological therapy incorporating biofeedback training by any modality (face‐to‐face with the patient) with psychotherapy(insight oriented, behavior modifying or supportive), approximately 20‐30 minutes

90876 Individual psychophysiological therapy incorporating biofeedback training by any modality (face‐to‐face with the patient) with psychotherapy(insight oriented, behavior modifying or supportive), approximately 45‐50 minutes

90880 Hypnotherapy

90901 Biofeedback training by any modality

96100 Psychological testing; not in use after 2006 – replaced by 3 new codes

96151 Health and behavior re‐assessment

96152 Health and behavior intervention, each 15 minutes, face‐to‐face, individual

96153 Health and behavior intervention, group (2 or more patients)

96154 Health and behavior intervention family with the patient present

96155 Health and behavior intervention family without the patient present

99241 Office consultation – new or established – problem focused – 15 minutes