State variation in psychotropic medication use by foster care children with autism spectrum disorder

Abstract

Objective: The objective of this study was to compare on a national cohort of children with autism spectrum disorder (ASD) the concurrent use of >or=3 psychotropic medications between children in foster care and children who have disabilities and receive Supplemental Security Income, and to describe variation among states in the use of these medications by children in foster care.

Methods: Studied was the concurrent use of >or=3 classes of psychotropic medications, identified from the 2001 Medicaid claims of 43406 children who were aged 3 to 18 years and had >or=1 annual claim for ASD. Medicaid enrollment as a child in foster care versus a child with disabilities was compared. Multilevel logistic regression, clustered at the state level and controlling for demographics and comorbidities, yielded standardized (adjusted) estimates of concurrent use of >or=3 medications and estimated variation in medication use within states that exceeded 1 and 2 SDs from the average across states.

Results: Among children in foster care, 20.8% used >or=3 classes of medication concurrently, compared with 10.1% of children who were classified as having a disability. Differences grew in relationship to overall use of medications within a state; for every 5% increase in concurrent use of >or=3 medication classes by a state's population with disabilities, such use by children in a state's foster care population increased by 8.3%. Forty-three percent (22) of states were >1 SD from the adjusted mean for children who were using >or=3 medications concurrently, and 14% (7) of the states exceeded 2 SDs.

Conclusions: Among children with ASD, children in foster care were more likely to use >or=3 medications concurrently than children with disabilities. State-level differences underscore policy or programmatic differences that might affect the receipt of medications in this population.

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 largest child welfare populations. The line represents equal proportions between foster care and SSI population for reference.

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 for each state. The adjusted estimates and CIs are based on the results of a mixed-effects logistic regression model and depict the state-specific random effects and their 95% CIs, all transformed from log odds to proportions.