Skip to main content

Advertisement

SpringerLink
Log in

The Complexity of Psychotropic Medication Prescription and Treating Trauma Among Youth in Foster Care: Perspectives from the Lived Experience

  • Original Article
  • Published:
Administration and Policy in Mental Health and Mental Health Services Research Aims and scope Submit manuscript

Abstract

Youth in the US foster care system are disproportionately prescribed antipsychotic and psychotropic medication compared to youth not involved with foster care. Research on the relationship between experiences of trauma, mental health symptoms, evidence-based treatment, and safe psychotropic prescribing practices for youth in foster care is limited. We explored stakeholders’ perspectives of the relationship between psychotropic medications and trauma informed care (TIC) for youth in foster care. We conducted semi-structured individual and group interviews with foster caregivers, caseworkers, prescribing clinicians, and alumni of the foster care system. Data were recorded and transcribed verbatim, and analyzed using a directed content analysis approach. Five themes emerged across and within stakeholder groups: (1) acknowledging trauma; (2) role of psychotropic medication; (3) psychosocial resources; (4) additional supports; and, (5) training and education. Stakeholders identified TIC as an important component of mental health services for youth in foster care. There was not consensus around the role of psychotropic medication in treating trauma; however, most stakeholders felt that it was overused. Respondents suggested including additional supportive team members to help guide youth through the mental health treatment system, and emphasized the importance of support from individuals with common lived experiences. Results demonstrate the need for a system that emphasizes trauma-sensitive clinical interactions and psychosocial supports. Improving training and education for stakeholders, and providing additional sources of support for youth in foster care, could help better identify and treat the effects of trauma and the safe pharmacotherapy for youth in foster care.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  • Abel, C., Goldsmith, C., & Marzerka, M. (2019). Pharmacists can improve medication management in the vulnerable population of foster care youth. Journal of the American Pharmacists Association, 59(5), 629–632.

    Article  PubMed  Google Scholar 

  • Akincigil, A., Mackie, T. I., Cook, S., Hilt, R. J., & Crystal, S. (2020). Effectiveness of mandatory peer review to reduce antipsychotic prescriptions for Medicaid-insured children. Health Services Research, 55(4), 596–603.

    Article  PubMed  PubMed Central  Google Scholar 

  • American Academy of Pediatrics. (2005). Fostering health: Health care for children and adolescents in foster care (2nd ed.). American Academy of Pediatrics District II.

    Google Scholar 

  • American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). American Psychiatric Association.

    Google Scholar 

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association.

    Book  Google Scholar 

  • Barnett, E., Butcher, R., Neubacher, K., Jankowski, M., Daviss, W., Carluzzo, K., Ungarelli, E. G., & Yackley, C. (2016). Psychotropic medications in child welfare: From federal mandate to direct care. Children and Youth Services Review, 66, 9–17.

    Article  Google Scholar 

  • Brenner, S. L., Southerland, D. G., Burns, B. J., Wagner, H. R., & Farmer, E. M. Z. (2014). Use of psychotropic medications among youth in treatment foster care. Journal of Child and Family Studies, 23(4), 666–674.

    Article  PubMed  PubMed Central  Google Scholar 

  • Child and Family Services Improvement and Innovation Act, Pub. L. No. 112–34, 42 U.S.C. § 1305 C.F.R. (2011). Retrieved from https://www.congress.gov/112/plaws/publ34/PLAW-112publ34.pdf

  • Child Welfare Information Gateway. (2015). Supporting youth in foster care in making healthy choices: A guide for caregivers and caseworkers on trauma, treatment, and psychotropic medications. U.S. Department of Health and Human Services, Administration for Children and Families, Children’s Bureau. Retrieved from https://www.childwelfare.gov/pubPDFs/mhc_caregivers.pdf

  • Child Welfare Information Gateway. (2020). The importance of a trauma-informed child welfare system. U.S. Department of Health and Human Services, Administration for Children and Families, Children's Bureau. Retrieved from https://www.childwelfare.gov/pubPDFs/trauma_informed.pdf

  • Cloitre, M., Stolbach, B., Herman, J., Kolk, B., Pynoos, R., Wang, J., & Petkova, E. (2009). A developmental approach to complex PTSD: Childhood and adult cumulative trauma as predictors of symptom complexity. Journal of Traumatic Stress, 22(5), 399–408.

    Article  PubMed  Google Scholar 

  • Colvin, M., & Miller, S. (2018). Serving clients and the community better: A mixed-methods analysis of benefits experienced when organizations collaborate in child welfare. Child & Family Social Work, 23(4), 666–675.

    Article  Google Scholar 

  • Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., DeRose, R., Hubbard, R., Kagan, R., Liataud, J., Mallah, K., Olafson, E., & van der Kolk, B. (2005). Complex trauma in children and adolescents. Psychiatric Annals, 35(5), 390–398.

    Article  Google Scholar 

  • Courtois, C. A. (2004). Complex trauma, complex reactions: Assessment and treatment. Psychotherapy: Theory, Research, Practice, Training, 41(4), 412–425.

    Article  Google Scholar 

  • Crystal, S., Mackie, T., Fenton, M. C., Amin, S., Neese-Todd, S., Olfson, M., & Bilder, S. (2016). Rapid growth of antipsychotic prescriptions for children who are publicly insured has ceased, but concerns remain. Health Affairs, 35(6), 974–982.

    Article  PubMed  Google Scholar 

  • Crystal, S., Olfson, M., Huang, C., Pincus, H., & Gerhard, T. (2009). Broadened use of atypical antipsychotics: Safety, effectiveness and policy challenges. Health Affairs, 28(Suppl1), w770–w781.

    Article  PubMed  Google Scholar 

  • Crystal, S., Mackie, T., Simmel, C., Akincigil, A., Neese-Todd, S., Cook, S., & Hermida, R. (2021). Examining effects of state policies to monitor mental health medicines for children in foster care. Patient-Centered Outcomes Research Institute (PCORI). https://doi.org/10.25302/02.2021.IHS.140923194

    Article  Google Scholar 

  • Dedoose Version 8.3.17, web application for managing, analyzing, and presenting qualitative and mixed method research data. (2020). Los Angeles, CA: SocioCultural Research Consultants, LLC Retrieved from www.dedoose.com

  • DosReis, S., Yoon, Y., Rubin, D. M., Riddle, M. A., Noll, E., & Rothbard, A. (2011). Antipsychotic treatment among youth in foster care. Pediatrics, 128(6), e1459–e1466.

    Article  PubMed  PubMed Central  Google Scholar 

  • Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258.

    Article  CAS  PubMed  Google Scholar 

  • Finnerty, M., Neese-Todd, S., Pritam, R., Leckman-Westin, E., Bilder, S., Byron, S., Scholle, S. H., Crystal, S., & Olfson, M. (2016). Access to psychosocial services prior to starting antipsychotic treatment among medicaid insured youth. Journal of the American Academy of Child and Adolescent Psychiatry, 55(1), 69–76.

    Article  PubMed  Google Scholar 

  • Fontanella, C. A., Warner, L. A., Phillips, G. S., Bridge, J. A., & Campo, J. V. (2014). Trends in psychotropic polypharmacy among youths enrolled in Ohio Medicaid, 2002–2008. Psychiatric Services, 65(11), 1332–1340.

    Article  PubMed  Google Scholar 

  • Fostering Connections to Success and Increasing Adoptions Act of 2008, Pub. L. No. 110–351. (2008). Retrieved from https://www.congress.gov/110/plaws/publ351/PLAW-110publ351.pdf

  • Fratto, C. (2016). Trauma-informed care for youth in foster care. Archives of Psychiatric Nursing, 30(3), 439–446.

    Article  PubMed  Google Scholar 

  • Griffin, G., McClelland, G., Holzberg, M., Stolbach, B., Maj, N., & Kisiel, C. (2011). Addressing the impact of trauma before diagnosing mental illness in child welfare. Child Welfare, 90(6), 69.

    PubMed  Google Scholar 

  • Herman, J. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5(3), 377–391.

    Article  Google Scholar 

  • Howie, L. D., Pastor, P. N., & Lukacs, S. L. (2014). Use of medication prescribed for emotional or behavioral difficulties among children aged 6–17 years in the United States, 2011–2012. NCHS data brief, no 148. National Center for Health Statistics.

    Google Scholar 

  • Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288.

    Article  PubMed  Google Scholar 

  • Keast, S. L., Tidmore, L. M., Shropshire, D., Nesser, N., & Lambert, T. L. (2019). Characterization of chronic multiclass psychotropic polypharmacy and psychotherapy in foster care youth in a state medicaid population. Journal of Managed Care & Specialty Pharmacy, 25(12), 1340–1348.

    Article  Google Scholar 

  • Knapp, P., Chait, A., Pappadopulos, E., Crystal, S., & Jensen, P. S. (2012). Treatment of maladaptive aggression in youth: CERT guidelines. I. Engagement, assessment, and management. Pediatrics, 129(6), e1562–e1576.

    Article  PubMed  Google Scholar 

  • Ko, S., Ford, J., Kassam-Adams, N., Berkowitz, S., Wilson, C., Wong, M., Brymer, M., & Layne, C. (2008). Creating trauma-informed systems: Child welfare, education, first responders, health care, juvenile justice. Professional Psychology: Research and Practice, 39(4), 396–404.

    Article  Google Scholar 

  • Kramer, T., Sigel, B., Conners-Burrow, N., Savary, P., & Tempel, A. (2013). A statewide introduction of trauma-informed care in a child welfare system. Children and Youth Services Review, 35(1), 19–24.

    Article  Google Scholar 

  • Kumar, S. A., Brand, B. L., & Courtois, C. A. (2019). The need for trauma training: Clinicians’ reactions to training on complex trauma. Psychological Trauma: Theory, Research, Practice, and Policy.

  • Kutz, G. D. (2011). Foster children: HHS guidance could help states improve oversight of psychotropic prescriptions. United States Government Accountability Office. Retrieved from https://www.gao.gov/assets/590/586906.pdf

  • Lee, B. R., Munson, M. R., Ware, N. C., Ollie, M. T., Scott, L. D., & McMillen, J. C. (2006). Experiences of and attitudes toward mental health services among older youths in foster care. Psychiatric Services, 57(4), 487–492.

    Article  PubMed  Google Scholar 

  • Leslie, L. K., Raghavan, R., Zhang, J., & Aarons, G. A. (2010). Rates of psychotropic\medication use over time among youth in child welfare/child protective services. Journal of Child and Adolescent Psychopharmacology, 20(2), 135–143.

    Article  PubMed  PubMed Central  Google Scholar 

  • Longhofer, J., Floersch, J., & Okpych, N. (2011). Foster youth and psychotropic treatment: Where next? Children and Youth Services Review, 33(2), 395–404.

    Article  Google Scholar 

  • Lucio, R., & Nelson, T. L. (2016). Effective practices in the treatment of trauma in children and adolescents: From guidelines to organizational practices. Journal of Evidence-Informed Social Work, 13(5), 469–478.

    Article  PubMed  Google Scholar 

  • Lyons, J., & Rogers, L. (2004). The US child welfare system: A de facto public behavioral health care system. Journal of the American Academy of Child & Adolescent Psychiatry, 43(8), 971–973.

    Article  Google Scholar 

  • Mackie, T. I., Cook, S., Crystal, S., Olfson, M., & Akincigil, A. (2020). Antipsychotic use among youth in foster care enrolled in a specialized managed care organization intervention. Journal of the American Academy of Child & Adolescent Psychiatry, 59(1), 166–176.

    Article  Google Scholar 

  • Mackie, T. I., Kovacs, K. M., Simmel, C., Crystal, S., Neese-Todd, S., & Akincigil, A. (2020). A best-worst scaling experiment to identify patient-centered claims-based outcomes for evaluation of pediatric antipsychotic monitoring programs. Health Services Research, 56(3), 418–431. https://doi.org/10.1111/1475-6773.13610

    Article  PubMed  PubMed Central  Google Scholar 

  • McMillen, J. C., Fedoravicius, N., Rowe, J., Zima, B. T., & Ware, N. (2007). A crisis of credibility: Professionals’ concerns about the psychiatric care provided to clients of the child welfare system. Administration and Policy in Mental Health and Mental Health Services Research, 34(3), 203–212.

    Article  PubMed  Google Scholar 

  • Mitchell, M. B. (2018). “No one acknowledged my loss and hurt”: Non-death loss, grief, and trauma in foster care. Child and Adolescent Social Work Journal, 35, 1–9.

    Article  Google Scholar 

  • Moses, T., & Kirk, S. A. (2006). Social workers’ attitudes about psychotropic drug treatment with youths. Social Work, 51(3), 211–222.

    Article  PubMed  Google Scholar 

  • National Child Traumatic Stress Network. (n.d.). Effects of complex trauma. Retrieved from https://www.nctsn.org/what-is-child-trauma/trauma-types/complex-trauma/effects

  • Olfson, M., Blanco, C., Liu, L., Moreno, C., & Laje, G. (2006). National trends in the outpatient treatment of children and adolescents with antipsychotic drugs. Archives of General Psychiatry, 63(6), 679–685.

    Article  PubMed  Google Scholar 

  • Pappadopulos, E., Macintyre Ii, J. C., Crismon, M. L., Findling, R. L., Malone, R. P., Derivan, A., Schooler, N., Sikich, L., Greenhill, L., Schur, S. B., Felton, C. J., Krazler, H., Rube, D. M., Sverd, J., Finnerty, M., Ketner, S., Siennick, S. E., & Jensen, P. S. (2003). Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part II. Journal of the American Academy of Child & Adolescent Psychiatry, 42(2), 145–161.

    Article  Google Scholar 

  • Pecora, P. J., Jensen, P. S., Romanelli, L. H., Jackson, L. J., & Ortiz, A. (2009). Mental health services for children placed in foster care: An overview of current challenges. Child Welfare, 88(1), 5–26.

    PubMed  PubMed Central  Google Scholar 

  • Rosenfield, P., Stratyner, A., Tufekcioglu, S., Karabell, S., McKelvey, J., & Litt, L. (2018). Complex PTSD in ICD-11: A case report on a new diagnosis. Journal of Psychiatric Practice., 24(5), 364–370.

    Article  PubMed  Google Scholar 

  • Rothwell, E., Anderson, R., & Botkin, J. R. (2016). Deliberative discussion focus groups. Qualitative Health Research, 26(6), 734–740.

    Article  PubMed  Google Scholar 

  • Saldaña, S. N., Keeshin, B. R., Wehry, A. M., Blom, T. J., Sorter, M. T., DelBello, M. P., & Strawn, J. R. (2014). Antipsychotic polypharmacy in children and adolescents at discharge from psychiatric hospitalization. Pharmacotherapy the Journal of Human Pharmacology and Drug Therapy, 34(8), 836–844.

    Article  Google Scholar 

  • Scotto Rosato, N., & Correll, C. U. (2012). Treatment of Maladaptive Aggression in Youth (T-MAY). CERT guidelines II. Psychosocial interventions, medication treatments, and side effects management. Pediatrics, 129, e1577–e1586.

    Article  PubMed  Google Scholar 

  • Scozzaro, C., & Janikowski, T. P. (2014). Mental health diagnosis, medication, treatment and placement milieu of children in foster care. Journal of Child and Family Studies, 24(9), 2560–2567.

    Article  Google Scholar 

  • Simmel, C., Bowden, C. F., Neese-Todd, S., Hyde, J., & Crystal, S. (2021). Antipsychotic treatment for youth in foster care: Perspectives on improving youths’ experiences in providing informed consent. American Journal of Orthopsychiatry, 91(2), 258–270.

    Article  PubMed  Google Scholar 

  • Soleimanpour, S., Geierstanger, S., & Brindis, C. D. (2017). Adverse childhood experiences and resilience: Addressing the unique needs of adolescents. Academic Pediatrics, 17(7), S108–S114.

    Article  PubMed  Google Scholar 

  • Spinazzola, S., Habib, M., Knoverek, A., Arvidson, J., Nisenbaum, J., Wentworth, R., Hogdon, H., Pond, A., & Kisiel, C. (2013). the heart of the matter: Complex trauma in child welfare. CW360 Trauma-informed Child Welfare Practice, Winter, 8–9.

  • Stroul, B. (2002). Systems of care: A framework for system reform in children’s mental health [Issue Brief]. University Child Development Center, National Technical Assistance Center for Children’s Mental Health.

  • Stroul, B. A. (2013). Analysis of System of Care Expansion Planning Grant Program: Description of Expansion Plans Developed by the First Cohort of Grantees. Technical Assistance Partnership for Child and Family Mental Health. Retrieved from https://www.yumpu.com/en/document/read/27043834/analysis-of-system-of-care-expansion-planning-grant-program

  • Substance Abuse and Mental Health Services Administration. (2019) Guidance on Strategies to Promote Best Practice in Antipsychotic Prescribing for Children and Adolescents. HHS Publication No. PEP19‐ANTIPSYCHOTIC‐BP. Office of Chief Medical Officer. Substance Abuse and Mental Health Services Administration.

  • Substance Abuse and Mental Health Services Administration’s Trauma and Justice Strategic Initiative. (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Substance Abuse and Mental Health Services Administration.

  • Sullivan, K., Murray, K., Ake, G., Hanson, R., & Lang, J. (2016). Trauma-informed care for children in the child welfare system: An initial evaluation of a trauma-informed parenting workshop. Child Maltreatment, 21(2), 147–155.

    Article  PubMed  Google Scholar 

  • U.S. Department of Health and Human Services, Administration for Children and Families. (2012). Information Memorandum: ACYF-CB-IM-12–04. Children’s Bureau. Retrieved from https://www.acf.hhs.gov/sites/default/files/documents/cb/im1204.pdf

  • U.S. Department of Health and Human Services, Administration for Children and Families. (2019). The AFCARS Report. Children’s Bureau. Retrieved from https://www.acf.hhs.gov/sites/default/files/documents/cb/afcarsreport27.pdf

  • van der Kolk, B. A., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (2005). Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress, 18(5), 389–399.

    Article  PubMed  Google Scholar 

  • Yin, R. K. (2015). Qualitative research from start to finish. Guilford publications.

    Google Scholar 

  • Yoon, Y., Rubin, D. M., Riddle, M. A., Noll, E., & Rothbard, A. (2011). Antipsychotic treatment among youth in foster care. Pediatrics, 128(6), e1459–e1466.

    Article  PubMed  PubMed Central  Google Scholar 

  • Zito, J. M., Safer, D. J., Sai, D., Gardner, J. F., Thomas, D., Coombes, P., Dubowski, M., & Mendez-Lewis, M. (2008). Psychotropic medication patterns among youth in foster care. Pediatrics, 121(1), e157–e163.

    Article  PubMed  Google Scholar 

Download references

Funding

This work was supported by the Patient-Centered Outcomes Research Institute (Grant No. IHS-1409-23194) and the Agency for Healthcare Research and Quality (Grant No. 1RO1 HS02600101A1), with additional support from the National Center for Advancing Translational Sciences (Grant No. UL1TR003017).

Author information

Authors and Affiliations

  1. School of Social Work, Rutgers University, 390 George Street, New Brunswick, NJ, 08901, USA

    Cadence F. Bowden, Cassandra Simmel, Alicia Mendez, Melanie Yu & Stephen Crystal

  2. Institute for Health, Health Care Policy and Aging Research, Rutgers University, 112 Paterson Street, New Brunswick, NJ, 08901, USA

    Sheree Neese-Todd & Stephen Crystal

Authors
  1. Cadence F. Bowden
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Cassandra Simmel
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Alicia Mendez
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Melanie Yu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sheree Neese-Todd
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Stephen Crystal
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Cassandra Simmel.

Ethics declarations

Conflict of interest

The authors have no relevant financial or non-financial interests to disclose. The authors have no conflicts of interest to declare that are relevant to the content of this article. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. The authors have no financial or proprietary interests in any material discussed in this article.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Rutgers University Institutional Review Board (Simmel:15-785M).

Standards of Reporting

The Consolidated criteria for Reporting Qualitative research (COREQ) checklist was employed when conducting this research. The COREQ checklist is provided as a supplementary file to our manuscript and methodological steps are detailed in the manuscript.

Consent to Participate

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 29 KB)

Supplementary file2 (DOCX 191 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bowden, C.F., Simmel, C., Mendez, A. et al. The Complexity of Psychotropic Medication Prescription and Treating Trauma Among Youth in Foster Care: Perspectives from the Lived Experience. Adm Policy Ment Health 49, 821–833 (2022). https://doi.org/10.1007/s10488-022-01203-4

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10488-022-01203-4

Keywords

Search

Navigation