Of the 43 306 children in the study, 9.5% were in foster care and the remainder were classified as having disabilities within the SSI Program (). Fifty-eight percent used at least 1 psychotropic medication during the year; 17% used psychotropic medications from ≥3 classes, and 11% used ≥ medication classes concurrently. Of the total sample, 32% were prescribed neuroleptics, 25% were prescribed antidepressants, 24% were prescribed stimulants, and 22% were prescribed anticonvulsants and/or lithium. The most prevalent comorbid diagnoses included attention-deficit disorder (22%), mental retardation (23%), and conduct disorder (14%).
Characteristics (%) of Children Aged 3 to 18 Years With a Diagnosis of ASD From 2001 Medicaid Claims According to Eligibility Group
Children in foster care differed from children with disabilities in demographic and clinical characteristics (). Nearly one third (29%) of children in foster care used ≥3 medication classes during the year, compared with 16% of children with disabilities. Children in foster care were also twice as likely to use ≥3 medication classes concurrently (21% vs 10%) than children with disabilities. By medication class, children in foster care were significantly more likely to receive neuroleptics (46% vs 31%), antidepressants (36% vs 24%), stimulants (37% vs 22%), and anticonvulsants/lithium (31% vs 21%). Children in foster care also disproportionately received diagnoses of attention-deficit disorder (36% vs 20%), conduct disorder (29% vs 12%), depression (11% vs 3%), and bipolar disorder (8% vs 3%). Groups were similar in their gender distribution and diagnosis of mental retardation.
Controlling for demographic and clinical characteristics, children in foster care were more likely than children in the SSI program to receive concurrently ≥3 medication classes and within classes to receive more neuroleptics, antidepressants, stimulants, and anticonvulsants (). The largest absolute and proportional differences between children in foster care and those in SSI were among 6- to 11-year-olds, including for concurrent use of ≥3 medication classes; any use of ≥3 medication classes; and individual class use of neuroleptics, antidepressants, stimulants, and anticonvulsants. Among 6- to 11-year-olds, the adjusted probability that children in foster care would use ≥3 medication classes concurrently was 49% greater (95% CI: 23%–74%) than the probability that children with disabilities would concurrently use such medications. In contrast, among 12- to 17-year-olds, the adjusted probability for such use among children in foster care was 32% greater (95% CI: 20%–46%) than for children with disabilities.
Standardized Percentage (95% CI) of Medication Use According to Age, Comparing Children Who Had ASD and Were in Foster Care With Children Who Had ASD and Were Receiving SSI in 2001
Across states, use of ≥3 medication classes during the year varied markedly (). Among states with at least 500 children in the cohort, the proportion of children who were in foster care and concurrently using ≥3 medication classes ranged from 5% to nearly 50%. Differences between the foster care and children who had disabilities and were receiving SSI in the use of ≥3 medication classes grew in relationship to the overall use of medications within a state; for every 5% point absolute increase in the concurrent use of ≥3 medication classes by a state’s SSI population, use by children in a state’s foster care population increased by 8.3% points (95% CI: 5.1%–11.5%; P = .041).
FIGURE 1 State variation in concurrent use of medications by children who had ASD, were in foster care, and were receiving SSI. Shown are states with at least 500 children in the sample (circles proportional to sample size); highlighted are the 8 states with the (more ...)
After controlling for demographic and clinical characteristics, significant interstate variation remained in the concurrent use of ≥3 medications among children in foster care (). Twenty-two (43%) states were outliers from the overall average using a 16% tails for the distribution of states’ adjusted rates, and 7 (14% states) were outliers using 2.5% tails (P < .001 for random effects represented by states). Using the assumptions of the mixed-effects model used to arrive at these estimates, one would expect far fewer outliers (16 and 2), assuming variation by chance alone. These latter 7 states included 4 with low use (California, Minnesota, New York, and Oregon) and 3 with high use (Indiana, South Carolina, and Texas).
FIGURE 2 Interstate variation (raw and adjusted) in the concurrent receipt of ≥3 psychotropic medications by Medicaid-eligible children who were in foster care and had claims for ASD in 2001. Raw percentages and CIs are based on simple binomial proportions (more ...)