Center on Child and Family Outcomes, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St., Tufts MC #345, Boston, MA 02111, USA.
Child Abuse Negl. 2011 May;35(5):333-42. doi: 10.1016/j.chiabu.2011.01.012.
Public Law (P.L.) 110-351, the "Fostering Connections to Success Act," calls for state child welfare agencies to partner with Medicaid and pediatric experts to provide planning and oversight regarding the provision of health and mental health services, including medication, to children in state custody. Recent reports, media cases, and class action lawsuits suggest over-use of psychotropic medications to address the behavioral needs of children in the child welfare system. We examined geographic variability in psychotropic medication use across US child welfare agency catchment areas to determine how rates of psychotropic medication use vary in relation to child, community, child welfare, and health system-level factors.
Cross-sectional analysis of Wave 1 data for the 92 child welfare catchment areas participating in the National Survey of Child and Adolescent Well-being, a random probability sample of 2,504 children ages 2-15 years undergoing investigation for abuse and neglect. We employed multilevel regression modeling to examine the impact of catchment-level variables on medication use, controlling for child-level variables.
Fifteen percent of children reported taking psychotropic medications. Rates of medication use across catchment areas ranged widely from 0 to 40%, a 40-fold difference. On multi-level logistic regression modeling, older age (p<.001), male gender (p<.001), emotional and behavioral problems (p<.001), and insurance (p=.05) were associated with psychotropic medication use at the child-level. At the catchment-level, stressful environment within the child welfare system was negatively associated with medication use. No other catchment-level variables examined were found to explain use.
Striking disparities in medication use exist across catchment areas in this national sample. Of the catchment variables examined, only stressful environment was related to medication use.
These findings highlight significant geographic variation in medication use that most likely reflect both under-use and over-reliance on psychotropic medication. The link between child welfare environment and medication use suggests the influence of systemic, as opposed to clinical, causes of variation in medication use. This requires greater implementation of organizational processes governing quality of care for this highly vulnerable population.
公共法（P.L.）110-351，即“促进成功法案”，要求州儿童福利机构与医疗补助和儿科专家合作，为被州监管的儿童提供健康和精神卫生服务（包括药物治疗）的规划和监督。最近的报告、媒体案例和集体诉讼表明，过度使用精神药物来满足儿童福利系统中儿童的行为需求。我们研究了美国儿童福利机构服务区域内精神药物使用的地域差异，以确定精神药物使用的比率如何与儿童、社区、儿童福利和卫生系统因素相关。
对参与国家儿童和青少年福利调查的 92 个儿童福利服务区域的第 1 波数据进行横断面分析，这是对 2504 名年龄在 2-15 岁之间的正在接受虐待和忽视调查的儿童进行的随机概率抽样。我们采用多水平回归模型来检查服务区域层面变量对药物使用的影响，同时控制了儿童层面变量。
15%的儿童报告服用精神药物。各服务区域的药物使用率差异很大，从 0 到 40%不等，差异高达 40 倍。在多水平逻辑回归模型中，年龄较大（p<.001）、男性（p<.001）、情绪和行为问题（p<.001）以及保险（p=.05）与儿童层面的精神药物使用有关。在服务区域层面，儿童福利系统内的紧张环境与药物使用呈负相关。在检查的其他服务区域层面变量中，没有发现可以解释药物使用的变量。
在这个全国性样本中，不同服务区域之间的药物使用存在显著差异。在所检查的服务区域变量中，只有紧张的环境与药物使用有关。
这些发现突出了药物使用在服务区域之间存在显著差异，这很可能反映了精神药物的使用不足和过度依赖。儿童福利环境与药物使用之间的联系表明，药物使用差异的原因更多是系统的，而不是临床的。这需要为这一高度脆弱的人群实施更多的护理质量组织流程。
