Update on the Use of Psychotropic Medications in
Texas Foster Children: Fiscal Years 2002-2011

Printable Version (pdf)

The Health and Human Services Commission (HHSC), the Department of Family and Protective Services (DFPS) and the Department of State Health Services (DSHS) have coordinated since 2004 to better assess and implement strategies to ensure the appropriate prescribing of psychotropic medications to children in foster care and assist healthcare providers in prescribing psychotropic medications appropriately. 

In March of 2004, HHSC and DFPS convened the DFPS Advisory Committee on Psychotropic Medications, which issued a report and recommendations.  These recommendations included the establishment of a statewide clinical consultation and monitoring system.

Subsequently, an interagency group, comprised of HHSC, DFPS and DSHS, developed and released the Psychotropic Medication Utilization Parameters for Foster Children (published February 2005 and updated in January 2007).  The most recent update published in December 2010, along with other information is available at: http://www.dfps.state.tx.us/Child_Protection/medical/default.asp#psychotropic.

These best practice Parameters were distributed statewide for implementation in February 2005.  In June 2006, a report was released by DFPS, HHSC and DSHS, the Use of Psychoactive Medication in Texas Foster Children in FY 2005 (available at: http://www.dfps.state.tx.us/documents/about/pdf/2006-06_UsePsychMedsFosterChild.pdf ).  This report concluded that the overall use of psychotropic medications and polypharmacy in children in foster care declined after the release of the best practice Parameters. 

This update on the use of psychotropic medications in Texas children in foster care is based on that report and focuses on four of the eight criteria outlined in the Parameters.  These are the following.

* Prescribing psychotropic medications for very young children.

* Prescribing two or more medications from the same drug class concurrently.

* Five or more psychotropic medications prescribed concurrently.

* Absence of a mental health diagnosis.

The graphs and tables below summarize key information and provide updates related to this report, which is based on Medicaid prescription and medical claims data from state fiscal year 2002 to the most recent available year. Specifically, they show children receiving: psychotropic medications, two or more medications from the same drug class concurrently, and five or more medications concurrently. The tables provide additional information about those who received psychotropic medications and did not have a mental health diagnosis listed on Medicaid claim forms.

As the charts below show, psychotropic prescribing of all types has decreased since the release of the Parameters in early 2005 both in terms of the percentage of foster care children receiving them and in the overall percentage of children receiving medication regimens outside of the recommended criteria of the best practice Parameters.

FY 2011**

FY2010**

FY2009**

FY2008**

STAR HEALTH managed care program for children in foster care started 4/1/2008

FY2007

FY2006

FY2005

DSHS best practice Parameters released in February 2005

FY2004

FY2003

FY2002

*Percentages in the first row for total foster children are the percent of total foster children across that row only. All other percentages are the percent of children within a specific age group (calculated down the age group columns based on the number in that age group).

**Prescriptions for 2008 - 2010 were revised and updated to reflect the inclusion of additional drug formulations (same drugs but different versions such as extended release, higher or lower dosage, etc.) that had been released during those years and three new antipsychotics, Paliperidone (brand name Invega), Asenapine (brand name Saphris) and Iloperidone (brand name Fanapt), that were approved by the FDA after the initial drug lists for this study were compiled.

Table Notes. Data may have changed from previous versions of report due to various reasons, such as programming code changes, additional data becoming available, and additional drugs added to the list of psychotropic medications as described under ** above.

1. Total children in each group is taken from the State Fiscal Year Medicaid Eligibility File and is determined by the age of the child in months at the beginning of the fiscal year.  For example, Ages 0-2 includes up through the end of the 35th month after birth.

2. A child was considered to have gotten a psychotropic medication if any medication on the attached list was prescribed (filled and paid) at any time during the year in question.  If the child got any psychotropic medication that can also be used as an anti-seizure medication or as a treatment for allergies, then the non-mental health uses of those medications were deleted from the data as much as was possible. See Methodology section of the June 2006 report at http://www.dfps.state.tx.us/documents/about/pdf/2006-06_UsePsychMedsFosterChild.pdf for additional details.

3. Because many times psychotropic medications are prescribed very short term for medical illnesses (e.g. when undergoing an outpatient surgical procedure) or mental health problems (e.g. after a traumatic experience), or for psychiatric diagnoses for which they are found to be ineffective, it was decided to remove all data for children who did not receive a prescription for a psychotropic medication that lasted at least 60 days.  While this may seem long, it is important to remember that prescribers tend to write 30-day or longer prescriptions even at first diagnosis.  Many times these medications are not taken past a few days due to ineffectiveness, side effects, or failure to adhere to the prescribed regimen.  Therefore, it makes sense to concentrate efforts on those children who most likely were actually taking medications past an initial prescription.  This row for Ages 0-2 addresses the first half of Criteria 7 in the ‘Criteria Indicating Need for Further Review of a Child’s Clinical Status’ section of the “Psychotropic Medication Utilization Parameters for Foster Children” as published on the DFPS website, hereafter referred to as the Parameters.

4. This second line in this row shows the number of 3 year olds who got any medication for longer than 60 days that was not a stimulant medication.  This item addresses the last part of Criteria 7 in the Parameters.   

5. Class polypharmacy is defined as the concurrent prescription for 60 days or longer of two unique medications from the same class.  In the case of the class of mood stabilizers, where the evidence base supports the use of two medications concurrently, class polypharmacy is defined as the concurrent prescription of three or more meds for 60 days or longer.  See the note above for an explanation of the 60-day qualifier.  This row reflects Criteria 3 from the Parameters.

6. The prescription of five or more medications concurrently is defined as any five psychotropic medications prescribed at the same time for 60 days or longer.  This is a different type of polypharmacy from #5 above and is Criteria 2 from the Parameters.

7. This row represents any child who met either of the two polypharmacy criteria of the Parameters. 

8. No MH diagnosis is defined as no ICD 9 code reflecting any mental health diagnosis listed on any claim form for services at any time during the year.  The full June 2006 report contains a list of diagnosis codes used.

9. No MH diagnosis >60 days is defined as no ICD 9 code reflecting any psychiatric diagnosis listed on any claim form at any time during the year for those children who received greater than 60 days of any psychotropic medication.  This row addresses Criteria 1 from the Parameters.