Study Examines Psychotropic Medication Use Among North Carolina Foster Youth

Foster youth in North Carolina are being prescribed psychotropic medications at rates that reach as high as 82 percent among adolescents, according to a new mixed-methods study published in the Journal of Child and Family Studies. The research, led by Kimberlee Grier of Novant Health together with colleagues at the University of North Carolina at Chapel Hill, Duke University School of Medicine, Duke University School of Nursing, and Duke University, offers one of the most detailed portraits to date of how psychiatric drugs are prescribed to children in state custody, combining a large-scale analysis of Medicaid claims with in-depth interviews of the child welfare professionals who navigate these decisions every day. The findings reveal a system in which medication decisions are shaped less by clinical need alone than by the structural fractures running through both the child welfare and healthcare systems.

The quantitative backbone of the study draws on Medicaid claims data covering 14,915 foster youth in North Carolina. Using descriptive statistics, the researchers mapped prescription patterns across age, gender, race, and ethnicity, and the resulting picture is striking. While psychotropic medication use is broadly elevated among foster youth compared with their peers outside the system, the rates climb steeply with age, peaking among adolescents, where up to 82 percent of youth in certain groups received at least one psychotropic prescription. Psychotropic medications, a class that includes antidepressants, antipsychotics, stimulants, and mood stabilizers, act on the central nervous system to alter mood, cognition, or behavior, and their use in children requires careful monitoring of growth, metabolic effects, and cardiovascular risk. The sheer scale of prescribing observed in this population raises questions about whether the underlying trauma driving behavioral symptoms is being adequately addressed by means other than pharmacology.

To interpret the numbers, the team applied the Andersen and Newman Framework of Health Services Utilization, a widely used conceptual model in health services research that organizes the determinants of care into predisposing characteristics, enabling resources, and need. Predisposing factors include demographics such as age, gender, and race; enabling resources include insurance coverage, access to providers, and system infrastructure; and need refers to the underlying mental health conditions themselves. The framework proved useful because it forced the researchers to consider that high prescription rates cannot be understood as a simple function of illness. In the foster care population, enabling factors such as fragmented provider networks, high social worker turnover, and frequent placement changes may push prescribing in directions that do not always align with need, while predisposing factors such as race and ethnicity appear to influence which children receive which medications.

The qualitative arm of the study involved twelve child welfare professionals whose interviews were analyzed using established content analysis methods with NVivo software. Their accounts converged on a central theme: fragmentation. Foster youth routinely move between placements, and each move can mean a new school, a new caseworker, a new foster parent, and often a new physician. When a child arrives at a psychiatric appointment with an unfamiliar clinician who has incomplete access to prior records, the safest and most likely outcome may be to continue, adjust, or add medication rather than to undertake a careful reevaluation. Interviewees described how the instability of providers and social workers made it extraordinarily difficult to maintain continuity of care, meaning the coherent, longitudinal management of a child’s treatment over time. In such an environment, the prescription record can become a substitute for a clinical history that no single person holds.

The study’s demographic analyses add an equity dimension that the authors argue demands attention. Prescription patterns varied meaningfully by race and ethnicity, consistent with a broader literature documenting racial and ethnic disparities in pediatric mental health service use. Prior research in North Carolina Medicaid populations and in national samples has shown that Black children are overrepresented in the child welfare system yet often receive different patterns of mental health treatment, a dynamic that scholars have connected to the racialized history of child welfare policy. The interaction between overrepresentation in care and differential prescribing raises the possibility that some children receive more medication than their clinical presentation warrants while others receive less than they need, and that neither outcome reflects careful, individualized decision-making.

Gender also emerged as a significant axis of variation. Patterns of externalizing behaviors, which include aggression, impulsivity, and conduct problems, are known to differ between boys and girls, and these behavioral differences often drive referral pathways and medication decisions. The authors note that gender differences in neuropsychiatric conditions have biological as well as social contributors, and that prescribers working with limited information may rely on behavioral presentation rather than comprehensive assessment when deciding whether to initiate a psychotropic drug. For adolescent girls and boys alike, the adolescent years represent a developmental window in which the risks of pharmacological intervention, including metabolic and endocrine effects, intersect with heightened prescribing rates, making the age-related patterns in the data particularly consequential.

What makes the study methodologically notable is its integration of the two data streams. Mixed-methods designs of this kind are most powerful when the qualitative findings explain the statistical patterns rather than merely accompanying them, and here the interviews did exactly that. The 82 percent adolescent prescribing rates and the demographic variation in the claims data become more interpretable when placed alongside professionals’ descriptions of systems in which no one holds a complete picture of a child’s history. A prescriber confronting a traumatized adolescent with agitation and no reliable records faces a genuinely difficult clinical choice, and the study suggests that structural conditions, not individual negligence, are what routinely convert that difficulty into high-volume prescribing. This framing shifts the policy conversation from blaming individual clinicians toward reforming the architecture of care.

The authors are explicit about the implications. They call for systemic reforms that prioritize collaborative effort among healthcare providers, social services, foster parents, and policymakers, along with the widespread adoption of trauma-informed approaches. Trauma-informed care reframes challenging behaviors as adaptations to adversity rather than as primary disorders to be suppressed, and it asks that any pharmacological decision be situated within an understanding of the child’s exposure to maltreatment, loss, and placement instability. Practical reforms could include shared electronic records accessible across agencies, consistent medical home assignments for youth in care, dedicated roles for nurses or care coordinators who track medications across placements, and mandatory medication reviews that ask not only whether a drug should be started but whether it should be deprescribed. Prior studies have shown that prescribers rarely deprescribe psychotropic medications for children in foster care, so review mechanisms that actively reconsider existing regimens could be especially valuable.

The stakes extend well beyond North Carolina. National data have long documented that children in foster care experience mental health disorders at several times the rate of their peers, reflecting the trauma that brought them into care as well as the disruptions that follow. With roughly 12,000 children in foster care in North Carolina alone and hundreds of thousands nationwide, the prescribing patterns documented here represent a substantial public health concern. Unmonitored polypharmacy, in which children take multiple psychotropic agents simultaneously, carries risks of sedation, weight gain, diabetes, and movement disorders, and it may blunt the therapeutic relationships and psychosocial interventions that evidence shows can be effective for trauma-related conditions. The researchers argue that improving outcomes for this marginalized population requires treating medication management as a system-level problem, one that cannot be fixed in a prescription pad or a clinic but only in the structures connecting child welfare and healthcare.

Ultimately, the study offers both a warning and a roadmap. The warning is that the most vulnerable children in the state are receiving psychiatric medications within a system whose fragmentation makes careful stewardship nearly impossible, with rates and patterns that vary by age, gender, race, and ethnicity in ways that suggest inequity rather than individualized care. The roadmap is equally clear: invest in continuity, stabilize the workforce around each child, build collaborative and trauma-informed decision processes, and hold the system, rather than the child or the prescriber, responsible for the quality of care. If the findings prompt policymakers and healthcare leaders to redesign how mental health treatment reaches foster youth, the study’s mixed-methods approach, uniting the scale of claims data with the lived expertise of child welfare professionals, may prove as influential as its numbers.