Research Article: Stimulant and Atypical Antipsychotic Medications For Children Placed in Foster Homes

Date Published: January 9, 2013

Publisher: Public Library of Science

Author(s): L. Oriana Linares, Nuria Martinez-Martin, F. Xavier Castellanos, James G. Scott.


The purpose of this study is to examine the use of prescribed psychoactive medications in a prospective cohort of children shortly after they entered foster homes; and to identify demographics, maltreatment history, psychiatric diagnoses including ADHD comorbidity, and level of aggression that contribute to prescribed use of stimulant and atypical antipsychotic medication over time.

The sample included N = 252 children (nested in 95 sibling groups) followed for three years up to 4 yearly waves.

Nearly all (89%) met criteria for at least one of eight psychiatric diagnoses and 31% (75/252) used one or more prescribed psychoactive medications. Over half (55%) were diagnosed with Attention Deficit Hyperactivity Disorder (ADHD); of these 38% used stimulants and 36% used atypical antipsychotics. Of the 75 medicated children, 19% received ≥3 different classes of drugs over the course of the study. Stimulants (69%) and atypical antipsychotics (65%) were the most frequently used drugs among medicated children. Adjusted odds ratios (AOR) showed that male gender (AOR = 3.2; 95% CI = 1.5–9.3), African American vs Latino ethnicity (AOR = 5.4; 95% CI = 2.1–14.2), ADHD regardless of Oppositional Defiant (ODD) or Conduct (CD) comorbidity (AOR = 6.0, 95% CI = 1.3–27.5), ODD or CD (AOR = 11.1, 95% CI = 2.1–58.6), and Separation Anxiety (AOR = 2.0, 95% CI = 1.0–4.0) psychiatric disorders were associated with the use of prescribed stimulants; while male gender (AOR = 3.8, 95% CI = 1.5–9.3), African American vs Latino (AOR = 5.1, 95% CI = 1.2–9.2) or Mixed/Other ethnicity (AOR = 3.3, 95% CI = 1.9–13.7), ADHD regardless of ODD or CD comorbidity (AOR = 5.8, 95% CI = 1.2–28.7), ODD or CD (AOR = 13.9, 95% CI = 3.3–58.5), Major Depression/Dysthymia (AOR = 2.8, 95% CI = 1.1–6.7) psychiatric disorders, and history of sexual abuse (AOR = 4.6, 95% CI = 1.3–18.4) were associated with the use of prescribed atypical antipsychotics.

The aggressive use of atypical antipsychotics, which has unknown metabolic risks, suggests that the efficacy and safety of such treatment strategies for psychiatrically ill children in foster care should be monitored.

Partial Text

There were 415,000 children in the United States in foster care in 2010 [1]. Children in foster care experience environmental, social, biological and psychological risks factors prior to and during their stay in care that make them particularly vulnerable to problems of over-activity and inattention [2], high aggression, and high rates of disruptive behavior disorders including Attention Deficit Hyperactivity (ADHD), Oppositional Defiant (ODD), and Conduct Disorders (CD) requiring multilevel treatments including psychiatric interventions [3], [4], [5]. Children placed in foster homes experience higher rates of physical and emotional problems than those in the general population; approximately 60% have a chronic medical condition, and 25% have ≥3 chronic problems; and developmental delays are present in approximately 60% of preschoolers. Children in foster care use both inpatient and outpatient mental health services at a rate 15 to 20 times higher than the general pediatric population. Between 40%–60% are found to meet criteria for at least one psychiatric disorder [6].

Table 1 shows psychosocial characteristics, C-DISC4 diagnoses, and use of prescribed psychoactive medication. Of the 252 children in our sample, there was a slight predominance of males (56%); racial and ethnic minorities were highly represented (African-American, 46%; Latinos, 26%); and about half (57%) of the children were in the youngest age group (3.0–7.9 years old). Over 76% of the children were classified as neglected, including a substantial proportion (40%) who had been exposed to domestic violence; and 22% were classified as abused, with physical abuse about four times as frequent as sexual abuse. At Wave 1, 35% and 30% of the children were at the clinical range for ECBI-PR Total and SESBI-R Total (T score ≥60) respectively.

As shown in other cross sectional studies [32], [10], [33], our sample of children in foster care in New York City exhibited a particularly high prevalence of Attention Deficit/Hyperactivity (55%), Oppositional Defiant (40%), and Conduct (25%) disorders. The high rates of Separation Anxiety disorder (46%) shown in our recent entrants to foster care are important to highlight; this finding may reflect the young age (mean of 7.76) of the children enrolled in the study and our multi-source approach in which the biological parent also contributed to psychiatric diagnostic data.