Study finds 1. 2 percent of preschoolers on Medicaid use psychotropic drugs

Using 2000-2003 Medicaid Analytic Extract data from 36 states, a group of researchers at the Brown School at Washington University in St. Louis and at Washington University School of Medicine in St. Louis found preschoolers are receiving psychotropic medications despite limited evidence supporting safety or efficacy.

The results of the study are published in the March issue of the American Journal of Public Health.

"Because we don't have indications in our data, it is not entirely clear why these children are receiving psychotropic drugs," said Lauren Garfield, PhD, lead author on the study, who was a postdoctoral research associate at the Brown School when the study was conducted and is now with Mercy Research in St. Louis.

"It is possible that some of these children have brain injuries or insults, such as traumatic brain injuries, fetal alcohol syndrome or the like, for which treatment is being provided. But if these medications are being used solely for behavioral control, then it seems clear that we need to better assess these children, and see if they might be better served by the use of evidence-based behavioral interventions," said Ramesh Raghavan, MD, PhD, co-author on the study, associate professor at the Brown School and associate professor of psychiatry at the School of Medicine.

Raghavan is currently on sabbatical from Washington University, serving at the Administration on Children and Families (ACF) in the U.S. Department of Health and Human Services in Washington.

The researchers followed children in two cohorts, born in 1999 and 2000, up to 4 years of age. They used logistic regression to model odds of receiving medications for attention-deficit disorder/attention-deficit hyperactivity disorder (ADHD), depression or anxiety and psychotic illness or bipolar.

Between 2000 and 2003, the researchers found that 1.19 percent of children received a prescription for any ADHD, depression or anxiety, or psychotic illness or bipolar medication. In addition, 0.17 percent of infants younger than 1 year old and 0.34 percent of children between 1 and 2 years were being prescribed psychotropic drugs.

Across ages and cohorts, 0.61 percent of children received a prescription for ADHD, 0.59 percent for depression or anxiety and 0.24 percent for psychotic illness or bipolar disorder.

"Although the absolute numbers and percentages of these drugs were small, these findings are worrying in so far as they indicate the use of psychotropic drugs among very young children," the authors wrote in the study.

"The fact that any children this small are using psychotropic drugs is very worrisome," said Raghavan.

"The existing evidence base in the area of trauma-informed psychosocial interventions warrants a large initial investment to expand access to effective interventions," said JooYeun Chang, associate commissioner of the Children's Bureau at the ACF.

Chang is helping to lead the effort on the federal level to reduce unnecessary psychotropic medication use among child welfare populations.

"The ACF budget request for $250 million over five years would fund infrastructure and capacity building, while the Medicaid investment of $500 million over five years would provide incentive payments to states that demonstrate measured improvement," she said. "This proposal presents a concerted effort to reduce over-prescription of psychotropic medications for these children by increasing the availability of evidence-based, psychosocial treatments that meet the complex needs of children who have experienced maltreatment. Increased access to timely and effective screening, assessment and non-pharmaceutical treatment will reduce over-prescription of psychotropic medication as a first-line treatment strategy, improve their emotional and behavioral health, and increase the likelihood that children in foster care will exit to positive, permanent settings, with the skills and resources they need to be successful in life."