Mental Health Diagnoses, Health Care Utilization, and Placement Stability on Antipsychotic Prescribing Among Foster Care Youth

Published:August 28, 2022DOI:



      This study sought to examine how mental health diagnoses, health care utilization and foster care placement instability affect antipsychotic prescribing and how these factors may contribute to disproportionate antipsychotic prescribing among youth in foster care.


      This retrospective cohort study utilized EHR data that were linked to administrative child welfare data. Two outcome variables were analyzed: 1) any antipsychotic prescription documented and 2) number of antipsychotic prescriptions documented. Predictor variables included foster care status, number of unique mental health diagnoses, counts of health care encounters over the study period, and counts of foster care placements. Covariates included gender, persons of color, and age in years. Models were estimated using logistic regression for the dichotomous outcome and Poisson regression for the count outcome.


      Increased antipsychotic prescribing among children in foster care persists even after accounting for mental health diagnoses and health care utilization. However, the number of placements modified the effect of foster care involvement on antipsychotic prescribing such that after 2 placement changes, the odds of being prescribed an antipsychotic surpassed the effect of foster care involvement. More mental health diagnoses, more inpatient and emergency health care encounters, and more foster care placements were associated with an increased odds of being prescribed an antipsychotic and an increased count of antipsychotic prescriptions. Decreased primary care encounters were associated with increased odds of antipsychotic prescriptions, and decreased specialty encounters were associated with higher counts of antipsychotic prescriptions.


      Placement instability is associated with disproportionate antipsychotic prescribing among youth in foster care.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Academic Pediatrics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • dosReis S
        • Yoon Y
        • Rubin DM
        • et al.
        Antipsychotic treatment among youth in foster care.
        Pediatrics. 2011; 128: e1459-e1466
        • Zito JM
        • Safer DJ
        • Sai D
        • et al.
        Psychotropic medication patterns among youth in foster care.
        Pediatrics. 2008; 121: e157-e163
        • Haque D
        • Haq T
        • Castillo L
        • et al.
        16.1 Comparison of off-label prescribing and psychosis in nonfoster abused and foster children.
        J Am Acad Child Adolesc Psychiatr. 2020; 59: S186
        • Leckman-Westin E
        • Finnerty M
        • Scholle SH
        • et al.
        Differences in Medicaid antipsychotic medication measures among children with SSI, foster care, and income-based aid.
        JMCP. 2018; 24: 238-246
      1. Pillay J, Boylan K, Carrey N, et al. First- and second-generation antipsychotics in children and young adults: systematic review update. Agency for Healthcare Research and Quality (US); 2017. Accessed February 22, 2022.

        • Galling B
        • Roldan A
        • Nielsen RE
        • et al.
        Type 2 diabetes mellitus in youth exposed to antipsychotics: a systematic review and meta-analysis.
        JAMA Psychiatr. 2016; 73: 247-259
        • Maayan L
        • Correll CU.
        Weight gain and metabolic risks associated with antipsycotic medications in children and adolescents.
        J Child Adolesc Psychopharmacol. 2011; 21: 517-535
        • Clausen JM
        • Landsverk J
        • Granger W
        • et al.
        Mental health problems of children in foster care.
        J Child Fam Stud. 1998; 7: 283-296
        • Stahmer AC
        • Leslie LK
        • Hurlburt M
        • et al.
        Developmental and behavioral needs and service use for young children in child welfare.
        Pediatrics. 2005; 116: 891-900
        • Engler AD
        • Sarpong KO
        • Van Horne BS
        • et al.
        A systematic review of mental health disorders of children in foster care.
        Trauma Violence Abuse. 2022; 23: 255-264
        • Vanderwerker L
        • Akincigil A
        • Olfson M
        • et al.
        Foster care, externalizing disorders, and antipsychotic use among Medicaid-enrolled youths.
        Psychiatric Services. 2014; 65: 1281-1284
        • Simms M.D.
        • Dubowitz H.
        • Szilagyi M.A.
        Health care needs of children in the foster care system.
        Pediatrics. 2000; 106: 909-918
        • Council on Foster Care
        • Szilagyi M.A.
        • Rosen D.S.
        • et al.
        Health care issues for children and adolescents in foster care and kinship care.
        Pediatrics. 2015; 136: e1131-e1140
        • dosReis S
        • Zito JM
        • Safer DJ
        • Soeken KL.
        Mental health services for youths in foster care and disabled youths.
        Am J Public Health. 2001; 91: 1094-1099
        • Finnerty M
        • Neese-Todd S
        • Pritam R
        • et al.
        Access to psychosocial services prior to starting antipsychotic treatment among Medicaid-insured youth.
        J Am Acad Child Adolescent Psychiatr. 2016; 55: 69-76.e3
        • Beal SJ
        • Nause K
        • Ammerman RT
        • et al.
        Careful: an administrative child welfare and electronic health records linked dataset.
        Data Brief. 2022; (in press)
        • Rubin DM
        • O'Reilly A
        • Luan X
        • et al.
        The impact of placement stability on behavioral well-being for children in foster care.
        Pediatrics. 2007; 119: 336-344
        • Leslie LK
        • Hurlburt MS
        • James S
        • et al.
        Relationship between entry into child welfare and mental health service use.
        Psychiatr Serv. 2005; 56: 981-987
        • Raghavan R
        • Inkelas M
        • Franke T
        • et al.
        Administrative barriers to the adoption of high-quality mental health services for children in foster care: a national study.
        Adm Policy Ment Health. 2007; 34: 191-201
        • Rubin DM
        • Alessandrini EA
        • Feudtner C
        • et al.
        Placement changes and emergency department visits in the first year of foster care.
        Pediatrics. 2004; 114: e354-e360
        • Beal SJ
        • Mara CA
        • Nause K
        • et al.
        Effects of child protective custody status and health risk behaviors on health care use among adolescents.
        Acad Pediatr. 2022; 22 (Published online): 387-395
        • Mackie TI
        • Hyde J
        • Palinkas LA
        • et al.
        Fostering psychotropic medication oversight for children in foster care: a national examination of states’ monitoring mechanisms.
        Adm Policy Ment Health. 2017; 44: 243-257