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Original research
Deprescribing psychotropic medications in children: results of a national qualitative study
  1. Erin R Barnett1,2,3,4,
  2. Alissa Z Trepman3,
  3. Hannah A Fuson3,5,
  4. Stephanie C Acquilano3,
  5. Jennifer L McLaren1,2,3,
  6. Steven Woloshin3,6,
  7. Joanna K Leyenaar2,3,7
  1. 1 Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
  2. 2 Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
  3. 3 Vulnerable Children Research Group, The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
  4. 4 Dartmouth Trauma Interventions Research Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
  5. 5 Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
  6. 6 Center for Medicine and Media at The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
  7. 7 Department of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, US
  1. Correspondence to Dr Erin R Barnett, Department of Psychiatry, Dartmouth College Geisel School of Medicine, Lebanon, NH 03755, USA; erin.r.barnett{at}dartmouth.edu

Abstract

Background and Objective Prescriptions for psychotropic medications to children have risen dramatically in recent years despite few regulatory approvals and growing concerns about side effects. Government policy and numerous programmes are attempting to curb this problem. However, the perspectives of practising clinicians have not been explored. To characterise the perspectives and experiences of paediatric primary care clinicians and mental health specialists regarding overprescribing and deprescribing psychotropic medications in children.

Methods We conducted 24 semistructured interviews with clinicians representing diverse geographic regions and practice settings in the USA. Interview questions focused on clinician perspectives surrounding overprescribing and experiences with deprescribing. We transcribed audio files verbatim and verified them for accuracy. We analysed transcripts using a grounded theory approach, identifying emergent themes and developing a conceptual model using axial coding.

Results Analysis yielded themes within four domains: social and clinical contextual factors contributing to overprescribing, opportunities for deprescribing, and facilitators and barriers to deprescribing in paediatric outpatient settings. Most participants recognised the problem of overprescribing, and they described complex clinical and social contextual factors, as well as internal and external pressures, that contribute to overprescribing. Opportunities for deprescribing included identification of high-risk medications, routine reassessment of medication needs and recognition of the broader social needs of vulnerable children. Facilitators and barriers to deprescribing were both internal (eg, providing psychoeducation to families) and external (eg, parent and child preferences) to clinicians.

Conclusion Our findings highlight a discrepancy between clinicians’ concerns about overprescribing and a lack of resources to support deprescribing in outpatient paediatric settings. To successfully initiate deprescribing, clinicians will need practical tools and organisational supports, as well as social resources for vulnerable families.

  • evidence-based medicine
  • mental health
  • paediatrics
  • qualitative research
  • health policy

https://doi.org/10.1136/bmjqs-2019-010033

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    Introduction

    Psychotropic polypharmacy and antipsychotic use among children has been steadily increasing, despite a lack of research support and few regulatory approvals. Psychotropic polypharmacy—defined as two or more psychotropic medications taken concurrently—occurs in an estimated 25%–42% of children with psychiatric needs in North American, European and African samples.1–3 Antipsychotic medications have also been increasingly prescribed to children internationally over the past 15 years,4–7 and the majority of these prescriptions are for off-label indications such as attention-deficit hyperactivity disorder (ADHD).7 Further, vulnerable children such as those in foster care, juvenile justice systems, residential or hospital facilities, and with developmental or intellectual disabilities are the most likely to receive high-risk psychotropic medications.8–14 Due to these concerns, governments and professional and health organisations have called for stricter oversight and improved clinical practice.15–19

    Deprescribing is the process of tapering and discontinuing medications, and it is integral to decreasing polypharmacy and unjustified use of medications at the patient level.20 21 Deprescribing has emerged as an important clinical construct within the larger context of medical overdiagnosis, overtreatment and overprescribing.21–25 The majority of international research on deprescribing has been conducted with the elderly, another population vulnerable to the harms of overprescribing.24 26 Deprescribing efforts in elderly and adult populations have successfully led to fewer psychotropic medications and lower costs without harm.21

    Deprescribing in paediatric populations has received less research attention, but is emerging as an innovative clinical practice in the USA.27 Preliminary studies within paediatric populations have demonstrated that psychotropic polypharmacy and antipsychotics can be safely reduced within residential treatment centres without re-emergence of challenging behaviours in children.28–33 Moreover, researchers observe reductions in adverse events and side effects,29 32 as well as substantial cost savings.10 34

    Although expert child and adolescent psychiatrists have called out the importance of deprescribing,27 no studies have assessed clinician perceptions—the majority of whom provide care in outpatient settings—in paediatric populations. In the USA, because both paediatric primary care clinicians (PCC) and mental health specialists (MHS) take active roles in paediatric mental healthcare delivery, understanding the perspectives of both stakeholder groups is fundamental to deprescribing initiatives. Therefore, we conducted a qualitative study to characterise the perspectives and experiences of PCCs and MHS regarding overprescribing and deprescribing in children, identifying facilitators and barriers to deprescribing in outpatient settings.

    Methods

    Our paper aligns with Enhancing the Quality and Transparency of Health Research network guidelines for publishing qualitative research in this field.35 As researchers, we recognise that our beliefs and assumptions influence our research. We acknowledge that our clinical research team is actively developing strategies to prevent overprescribing and promote deprescribing in vulnerable child populations.

    Participants

    Drawing on professional connections from an unrelated study, we contacted mental health professionals based at federally qualified public health centres across the USA. We requested introductions to the MHS at their centre who were primarily responsible for the care of children and adolescents. We contacted MHS by email to request their participation in this study. We then contacted, by email, PCCs who were independent from the identified MHS but who worked in the same communities, purposefully sampling paediatric primary care practices to identify participants in private practice, community health centres and academic medical centres.

    Twenty-four of the 39 providers invited (61.5%) agreed to participate in the study, including 13 PCCs (of 26) and 11 (of 13) MHS (table 1). Participants represented all geographic regions of the USA, and practised across urban, suburban and rural settings. All 13 PCCs were paediatricians; MHS included eight child and adolescent psychiatrists and three psychiatric nurse practitioners. Seven MHS reported serving exclusively or predominantly children and adolescents. All participants had prescribing privileges.

    View this table:
    Table 1

    Baseline characteristics (n=24)

    Procedures

    We developed semistructured interview guides for PCCs and MHS based on literature review and our clinical experiences (see online supplementary material for guides). We pilot tested two iterative versions of the guide with nine child and adolescent psychiatrists before study initiation. Five interviewers, all with Master of Arts or Doctor of Medicine degrees and with expertise in the topic area, conducted the interviews by telephone. All were audio recorded with permission. Interview questions focused on: (1) provider roles in the care of children with mental health conditions; (2) collaboration and communication between PCCs and MHS; (3) prescribing practices regarding psychotropic medications for children, including perspectives on overprescribing; and (4) experience with deprescribing psychotropic medications in children. The interviews were transcribed verbatim and verified for accuracy. Participants received a study information sheet via email when the interview was scheduled and provided verbal consent prior to the interview. Participants received a $100 gift card to recognise their participation. Participants also completed an online survey of their demographic and clinical practice characteristics. The Dartmouth Committee for the Protection of Human Subjects reviewed the study and deemed it exempt from further review.

    Supplemental material

    Supplemental material

    Analysis

    Using open coding, an approach rooted in grounded theory, members of the research team reviewed transcripts to identify emergent concepts related to prescribing and deprescribing psychotropic medications in paediatric outpatient settings. Emergent concepts and associated definitions were summarised in a collaboratively developed coding framework.36 37 Five members of the research team independently applied codes to a subset of transcripts; areas of coding disagreement were resolved through in-depth discussions of the concepts, codes and definitions. Following assurance of coding agreement, transcripts were uploaded to Dedoose,38 a mixed methods data management and analysis programme, and two members of the research team coded each transcript. Through this process, research team members agreed that data saturation had been attained. The research team then reviewed all codes and associated excerpts to group similar concepts into themes and domains. During this axial coding process, we identified temporal and conceptual relationships between our emergent themes and domains; this formed the basis of our conceptual framework.

    Results

    Our analysis yielded themes within four domains. Figure 1 summarises the major themes within these four domains, as well as how the themes are conceptually related.

    Figure 1
    Figure 1

    Conceptual model for deprescribing psychotropic medications in children. PCC, primary care clinician.

    Factors contributing to overprescribing

    When asked whether they were concerned about overprescribing, 17 of the 24 participants reported at least some concern (six reported no concerns, one response could not be coded). Perceptions of the social and clinical factors contributing to overprescribing centred around three major themes: internal pressures felt by clinical prescribers; pressures from parents and stakeholders; and inadequate mental health, educational, and social welfare systems and supports needed to prevent and mitigate the social, developmental and educational challenges faced by children and their families.

    Internal pressures felt by clinical prescribers

    Many participants spoke about the overwhelming pressures they felt to solve what are often complex social and mental health problems. When no other solutions were readily apparent, participants spoke about wanting to offer the family relief through medications, even if sometimes they could not address the root causes of the problems. For example:

    We [prescribers] sort of got caught up with a nice, easy solution and we forgot about the more complicated ‘what's going on in this kid's life?’ And that becomes overwhelming—because do you want to know everything if you can't do anything about it? (PCC 17)

    Pressures from parents and other stakeholders

    Participants described intense external pressures from parents, schools and other stakeholders to have children medicated as a means to reduce unwanted behaviours. Some participants described their beliefs that some parents want clinicians to diagnose their child and subsequently prescribe medications as a perceived ‘quick fix’ (MHS 10). One PCC described part of the problem as ‘Parents…are convinced that this child is sick and needs to be on all these things [medications]…or even teachers sometimes…so [they] can manage them’ (PCC 1). Participants also shared the perspective that parents and communities do not hold accurate beliefs about medications, with many holding unrealistic beliefs about the causes of their child’s difficulties and expectations about what the medications can help. One PCC stated: ‘Sometimes parents have expectations that are different than…the providers’ (PCC 11).

    Inadequate systems and supports for social, developmental and educational challenges

    Especially with respect to vulnerable groups of children such as those in foster care, participants spoke about mental health, education and social systems that they believe are unable to meet the needs of families. One pervasive concept within this theme was the practice of medicating behaviours and social problems, such as stressors at home and trauma. As one PCC stated: ‘It’s really easy to end up in scenarios where you’re actually medicating or at least being asked to medicate what’s a family problem’ (PCC 11).

    Participants described perceptions of inadequate educational structures that require certain behaviours in school, as well as stressed education systems: ‘Some of the classrooms are overcrowded …Teachers are kind of limited in what they can do anyways as far as discipline…’ (PCC 5).

    Overprescribing was also described as a potential unintended consequence of an overcrowded mental health system; because families struggle to access the intensity of services they need, children receive medications in an effort to reduce challenging behaviours. For example, one PCC reported: ‘I think it makes it easier on the psychiatrists [to] have them overmedicated and see them less often’ (PCC 7).

    Finally, participants specifically described poor coordination of care between various systems and providers. They described how overprescribing can occur when children unknowingly receive medications from different clinicians or pharmacies. Participants also described scenarios in which unknown non-adherence and diversion (eg, parents take or sell medication) contributes to overprescribing because it appears to the clinician that the medications are not working.

    Opportunities for deprescribing

    Participants identified a number of opportunities for deprescribing in outpatient settings. Key themes within this domain included: (1) recognition of medications most appropriate for deprescribing; (2) the importance of routine reassessment of medication needs; and (3) identifying the unique needs of vulnerable children. Of note, a few participants also discussed worries about underprescribing.

    Medications most appropriate for deprescribing

    Participants most frequently discussed concerns related to medications or medication combinations (eg, polypharmacy) with high risk-benefit ratios. These discussions were in the context of troubling side effects, often related to sedation, personality changes, or appetite and weight changes. As one PCC stated: ‘They're somnolent or just don't have the same personalities that they used to have, or they're not performing well in school or relating well’ (PCC 8). Polypharmacy led to added concerns about interactions between medications and confusion over which medications were helping, and which were causing side effects. For example, one PCC stated: ‘We just aren’t sure which medication is causing that side effect’ (PCC 8).

    Due to their side effect profiles, participants described the greatest concerns about antipsychotics and mood stabilisers. However, some participants, especially the PCCs, discussed concerns about the overuse of medications to treat ADHD even in the absence of major side effect concerns: ‘Everyone wants a stimulant so they can score higher on their ACT [American College Testing]…We all kind of feel the same, we’re just fed up with ADHD’ (PCC 9). Participants also shared concerns about children receiving medications—psychostimulants in particular—at doses higher than recommended: ‘We have some [children]…on like 70 of Vyvanse [lisdexamfetamine dimesylate] … an extreme dose’ (PCC 5).

    Another common component of this theme was concern about the use of medications without a clear rationale. For example, one MHS reported: ‘There can be so much complexity in the prescribing it’s just not rational. It starts interjecting a lot of potential risk…[and] falls away from evidence-base’ (MHS 4).

    Finally, participants noted how the presence of side effects can then be used to justify the start of new medications, leading to a cascade of polypharmacy: ‘You're chasing one medicine because of the side-effect of another medicine’ (PCC 11).

    Routine reassessment of medication needs

    Another perceived opportunity for deprescribing involved children who remained on psychotropic medications despite having matured and developed over time or having demonstrated clinical stability. For example, one PCC stated: ‘Because with kids, inherently they change… they get older, they learn new skills’ (PCC 11). Yet participants noted their beliefs that clinical prescribers do not often reassess the decision for medications over time, despite known and unknown impacts of long-term psychotropic medications on brain development.

    Unique needs of vulnerable children

    Participants voiced many concerns about overprescribing to children with social and medical vulnerabilities. They were worried about medications masking important underlying issues such as trauma and stress at home. As one PCC reported: ‘A medication is not going to take care of it [trauma and stress at home] and all we're doing is masking…’ (PCC 17). These discussions often emerged when participants described their care of children after psychiatric hospitalisations or residential placements, the majority of whom were described as having complex social challenges. For example: ‘They’ve [hospitals] had to ramp up their meds…Then they [children] say “I’m sleeping all the time and I can’t pay attention at school. I’m really sedated”’ (MHS 7). In addition, participants spoke about their concerns for children involved with the foster care system and those with medical complexities or intellectual or developmental disabilities. For example: ‘My kids in foster care, I’m noticing they are on up to four meds at a time’ (MHS 10).

    Facilitators of deprescribing

    Internal facilitators

    Participants described providing psychoeducation to families as the most common facilitator under their control as clinicians. They described educating children and parents about the goals of treatment, the risks and benefits of medications, and importantly, realistic expectations: ‘I think it’s important…to have those clear discussions with families about what our goals are, what we’re trying to treat…and what we’re not likely to achieve…’ (PCC 11). Sometimes this discussion included acknowledging that the ultimate goal of treatment is discontinuation of the medication. Clinicians also discussed providing psychoeducation on typical child development and other strategies to manage behaviours, normalise challenging behaviours and reduce the desire for medications. Participants also described preparing families with what to look for if problems reappear during or after deprescribing.

    Many participants spoke about the need to build trust and confidence with parents who feared worsening of symptoms. They described that part of building trust involved empowering children and parents in the process: ‘So I’ll say to the mom and the kid “I want you to each pick one medicine…if you’ve got to give up one today, which would you give up?”’ (MHS 7).

    When possible, participants stated that talking with the original clinical prescriber was helpful in understanding the rationale for the medication(s), leading to insights on whether and how to deprescribe. Participants—mostly MHS—also described how they go slow and monitor regularly, and how they use a stepwise approach to reduce or taper medications:

    [I] try to get as best a history from the parent or guardian and the patient…then, depending on how the patient is doing…slowly taper one medicine at a time, of the medicines that don't seem to be helpful…I try to take it step-wise and slow. (MHS 12)

    Some participants also held simple guidelines for themselves to prevent overmedicating children. They noted guidelines based on the child’s age: ‘…as a rule I try to avoid medicating anyone under the age of 6’ (MHS 7); the number of medications: ‘I try to do a single agent as much as I can no matter what…’ (PCC 14); or reducing doses/administrations when possible: ‘…I [have the child] just take it [stimulant] during the school week and not on the weekends’ (PCC 5).

    Finally, along with processes used directly with families, participants spoke about their personal efforts to build community awareness about the potential harms of overprescribing, typical child development and behaviours, and realistic expectations for medications. Through these efforts, they hoped to debunk beliefs and attitudes in their communities about medications being magic bullets.

    Of note, compared with PCCs, MHS appeared more confident in deprescribing and provided more details about the processes of deprescribing, including their own internal facilitators (eg, experience and confidence).

    External facilitators

    Participants described many factors outside of their control as helpful to the deprescribing process. They spoke about taking advantage of a child’s dislike for medication: ‘…a lot of the kids…hate taking medicine anyway. That helps the process in terms of saying, “Our goal is to get you on as little as possible, but still have you succeed”’ (PCC 8).

    Having other supports such as counselling or educational accommodations in place for the children and families when initiating the deprescribing process was also described as important: ‘We might have a conversation say, “Okay let’s make sure the counseling is still connected as we wean these medications off…”’ (PCC 11). As another example, one PCC reported ‘…they're not on any of this stuff [medications] anymore…and it’s mostly because we found the right schooling circumstance and/or the mom is feeling supported’ (PCC 17).

    Participants also described using consultation, trainings or other resources as helpful to the deprescribing process. Several of them spoke about how written deprescribing guidelines would be helpful to these efforts, such as a ‘…(deprescribing) goal and the plan, written, that can go in the medical record’ (PCC 16).

    Barriers to deprescribing

    The perceived barriers to deprescribing largely mirrored in reverse the perceived facilitators. However, a few unique themes emerged, organised by internal and external barriers.

    Internal barriers

    PCCs in particular spoke about discomfort deprescribing (and prescribing) medications with high risk-benefit ratios: ‘[Deprescribing] lays in the same realm as starting prescriptions. You should feel comfortable starting or stopping. If not, refer’ (PCC 16). Although several participants described engagement with the practice of deprescribing, some may not yet realise its legitimacy, with only 9 of the 24 participants having heard the term. Further, clinical prescribers may not be ready to acknowledge their own overprescribing, potentially hindering their initiation of deprescribing. With one exception, participants talked about others and not themselves engaging in overprescribing.

    External barriers

    The most common barrier discussed was that of parent fears: ‘…caregivers often times worry that behaviours are going to escalate or get out of control if we start reducing medications’ (MHS 5). Participants also worried about costs and availability of counselling services, as well as insurance or payer regulations that can prevent the use of medications that they view as more helpful or less risky. For example, ‘Somebody’s 12, they cannot take this [medication]. But if tomorrow, if they turn 13, it’s okay…the insurance companies don't look at the spectrum or, or the condition as a whole’ (MHS 8).

    Important to outpatient settings, participants spoke about not having enough time for intensive follow-up and monitoring due to an overcrowded mental health system. In addition, when specifically asked about collaboration or consultation between MHS and PCCs to deprescribe, very few participants had experiences collaborating: ‘The system is too crowded for psychiatrists to consult in a curbside manner for de-prescribing. I don't think they will have time for it, as much as we don't have time either’ (PCC 6).

    Discussion

    Our findings provide insight into paediatric prescribing clinicians’ beliefs and behaviours surrounding overprescribing and deprescribing psychotropic medications for children. Most participants reported concerns about overprescribing and described contributing factors such as under-resourced social, clinical and educational systems that cannot meet the needs of some families. Participants also described internal pressures to overprescribe, as well as pressures from parents and other stakeholders due to unrealistic expectations and desires for rapid clinical improvement. Many had engaged in deprescribing although few had heard the term. Although participants described a number of internal and external facilitators of deprescribing, they elaborated on complex barriers, particularly parent fears of worsening symptoms, and for PCCs, discomfort with the process.

    The opportunities for deprescribing identified in our study are harmonious with existing guidance in elderly populations and under development by child and adolescent psychiatry thought leaders. Guidelines recommend identifying medications with the worst risk-benefit ratios, those provided without clear rationale and those that are unlikely to be effective based on their off-label utilisation or lack of evidence base.20 39 40 Unlike prior studies in adult populations, the unique and complex needs of vulnerable children—including foster children and those having experienced trauma—emerged as an important theme in our research. In the absence of robust social and educational supports, clinicians may not be able to offer easy solutions for overprescribing in this population. However, clinicians can help caregivers understand the underlying causes of behaviours and promote realistic expectations for medications.

    A number of the deprescribing facilitators from our study are similar to those identified in prior literature with adult populations. Adult patients and their caregivers have described strong therapeutic relationships and psychoeducation as helpful to deprescribing.41 Existing deprescribing guidance also suggests the use of slow, monitored and stepwise processes similar to our findings.20 39 Our research suggests that facilitators external to the prescribing clinician may be equally important to deprescribing efforts. Clinicians may find it helpful to capitalise on children’s dislike of medications, which is demonstrated more frequently beginning around puberty.42 Further, many governments and communities are initiating programmes to reduce overprescribing and facilitate deprescribing of psychotropic medications in children, with programmes ranging from expert consultation services to audit and feedback initiatives.16 18

    The most commonly described barrier in our study was parent fears of worsening problems. PCCs caring for adults,24 as well as adult patients and their caregivers,41 have described similar fears of worsening symptoms. Yet deprescribing efforts have demonstrated safety and effectiveness in elderly populations.21 Further, preliminary research suggests that deprescribing high-risk psychotropic medications in children, at least in residential settings, reduces problem behaviours as well as adverse events.28–33 Deprescribing in outpatient settings may prove more challenging; our participants described concerns about having insufficient time to adequately follow-up and monitor patients in outpatient settings during the deprescribing process, which has also been reported as a barrier in adult outpatient settings.41

    Practice and policy implications

    This research has important implications for clinical practice and health policy. Our findings suggest that clinicians need support to identify and curb their overprescribing practices. Similar initiatives have been successful in reducing the use of antibiotics in children,43 44 and the field of antibiotic stewardship may offer several guiding principles for deprescribing of psychotropic medications, including multistakeholder engagement and social media campaigns. Clinicians will also need resources to assist them in clearly presenting the risks, benefits and realistic expectations for medications to patients, families and communities. Medical training programmes could emphasise therapeutic relationships, person-centred care and shared decision-making to facilitate deprescribing.39 Our findings may also be of benefit to professional societies and training and medication oversight programmes—within children’s mental health and elsewhere—to help curb overprescribing, establish deprescribing guidelines and formalise practices. Innovative changes to outpatient systems in the USA are needed to enable adequate follow-up and monitoring during deprescribing. Finally, we need to build the evidence base supporting which resources and oversight processes are the most effective in helping clinicians, patients and families acknowledge overprescribing and initiate deprescribing.45 Paediatric providers and administrators could adapt tools and strategies successful in elderly populations.26

    Limitations

    Several limitations warrant mention. First, we used different recruitment methods for MHS and PCCs. Differences in the perspectives discussed by these two groups could reflect an artefact of the differing recruitment methodologies. Because all of our MHS were practising in community health centres, academic medical centres and private practices were not represented; barriers and facilitators of deprescribing may differ in these settings. In addition, we did not take into account the perspectives of children and parents. Future research must strive to understand these perspectives to ensure that deprescribing initiatives are centred on their needs.

    Conclusions

    Psychotropic medication prescribing for children has increased considerably in recent years. In summarising the perspectives and experiences of a national sample of PCCs and MHS, our research provides valuable context about the internal and external factors that influence overprescribing and deprescribing. As articulated by our participants, clinicians would benefit from practical guidance and skills to facilitate deprescribing, as well as structures and policies that support deprescribing efforts in paediatric outpatient settings. Our findings can provide guidance to professionals and organisations attempting to curb overprescribing and deprescribe within the children’s mental health systems20 40 and other medical contexts.

    Acknowledgments

    This paper is dedicated in loving memory to Lisa Schwartz for her boundless dedication to the pursuits of our research team.

    References

    1. ↵
      2. Lohr WD ,
      3. Creel L ,
      4. Feygin Y , et al
      . Psychotropic polypharmacy among children and youth receiving Medicaid, 2012-2015. J Manag Care Spec Pharm 2018;24:736–44.doi:10.18553/jmcp.2018.24.8.736
      OpenUrl
    2. ↵
      2. Olashore A ,
      3. Ayugi J ,
      4. Opondo P
      . Prescribing pattern of psychotropic medications in child psychiatric practice in a mental referral hospital in Botswana. Pan Afr Med J 2017;26.doi:10.11604/pamj.2017.26.83.11212
    3. ↵
      2. Whiteside SP ,
      3. Sim LA ,
      4. Olsen MW , et al
      . The 5-year course of medication treatment in childhood anxiety disorders. J Clin Psychiatry 2019;80.doi:10.4088/JCP.18m12318
    4. ↵
      2. Kalverdijk LJ ,
      3. Tobi H ,
      4. van den Berg PB , et al
      . Use of antipsychotic drugs among Dutch youths between 1997 and 2005. Psychiatr Serv 2008;59:554–60.doi:10.1176/ps.2008.59.5.554
      OpenUrlCrossRefPubMedWeb of Science
    5. ↵
      2. Rani F ,
      3. Murray ML ,
      4. Byrne PJ , et al
      . Epidemiologic features of antipsychotic prescribing to children and adolescents in primary care in the United Kingdom. Pediatrics 2008;121:1002–9.doi:10.1542/peds.2007-2008
      OpenUrlAbstract/FREE Full Text
    6. ↵
      2. Vitiello B ,
      3. Correll C ,
      4. van Zwieten-Boot B , et al
      . Antipsychotics in children and adolescents: increasing use, evidence for efficacy and safety concerns. Eur Neuropsychopharmacol 2009;19:629–35.doi:10.1016/j.euroneuro.2009.04.008
      OpenUrlCrossRefPubMedWeb of Science
    7. ↵
      2. Olfson M ,
      3. King M ,
      4. Schoenbaum M
      . Treatment of young people with antipsychotic medications in the United States. JAMA Psychiatry 2015;72:867–74.doi:10.1001/jamapsychiatry.2015.0500
      OpenUrl
    8. ↵
      2. Read C
      . Personalised services: case studies. putting the past into the present. Health Serv J 2013;123:24–5.
      OpenUrl
    9. ↵
      2. Raghavan R ,
      3. Brown DS ,
      4. Allaire BT , et al
      . Medicaid expenditures on psychotropic medications for maltreated children: a study of 36 states. Psychiatr Serv 2014;65:1445–51.doi:10.1176/appi.ps.201400028
      OpenUrl
    10. ↵
      2. Brenner SL ,
      3. Southerland DG ,
      4. Burns BJ , et al
      . Use of psychotropic medications among youth in treatment foster care. J Child Fam Stud 2014;23:666–74.doi:10.1007/s10826-013-9882-3
      OpenUrl
    11. ↵
      2. Spencer D ,
      3. Marshall J ,
      4. Post B , et al
      . Psychotropic medication use and polypharmacy in children with autism spectrum disorders. Pediatrics 2013;132:833–40.doi:10.1542/peds.2012-3774
      OpenUrlAbstract/FREE Full Text
    12. ↵
      2. van Wattum PJ ,
      3. Fabius C ,
      4. Roos C , et al
      . Polypharmacy reduction in youth in a residential treatment center leads to positive treatment outcomes and significant cost savings. J Child Adolesc Psychopharmacol 2013;23:620–7.doi:10.1089/cap.2013.0014
      OpenUrl
    13. ↵
      2. Zito JM ,
      3. Safer DJ ,
      4. Sai D , et al
      . Psychotropic medication patterns among youth in foster care. Pediatrics 2008;121:e157–63.doi:10.1542/peds.2007-0212
      OpenUrlAbstract/FREE Full Text
    14. ↵
      2. Fontanella CA ,
      3. Warner LA ,
      4. Phillips GS , et al
      . Trends in psychotropic polypharmacy among Youths enrolled in Ohio Medicaid, 2002-2008. Psychiatr Serv 2014;65:1332–40.doi:10.1176/appi.ps.201300410
      OpenUrl
    15. ↵
      2. Kutz G
      . Foster children: HHS guidance could help states improve oversight of psychotropic prescriptions. Washington, DC: General Accounting Office, 2011.
    16. ↵
      2. Mackie TI ,
      3. Hyde J ,
      4. Palinkas LA , et al
      . Fostering Psychotropic Medication Oversight for Children in Foster Care: A National Examination of States’ Monitoring Mechanisms. Adm Policy Ment Health 2017;44:243–57.doi:10.1007/s10488-016-0721-x
      OpenUrl
    17. ↵
      1. US Department of Health and Human Services Administration for Children Youth and Families Children's Bureau
      . Information memorandum promoting the safe, appropriate, and effective use of psychotropic medication for children in foster care, 2012. Available: http://www.acf.hhs.gov/programs/cb/resource/im1203
    18. ↵
      1. Center for Health Care Strategies
      . Improving the use of psychotropic medication for children in foster care: state profiles, 2018. Available: https://www.chcs.org/resource/psychotropic-medication-stakeholder-engagement/
    19. ↵
      1. American Academy of Child and Adolescent Psychiatrists
      . AACAP position statement on oversight of psychotropic medication use for children in state custody: a best principles guideline, 2005. Available: https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/systems_of_care/FosterCare_BestPrinciples_FINAL.pdf
    20. ↵
      2. Bellonci C ,
      3. Carlson GA
      . 24.0 deprescribing in child and adolescent psychiatry: where, when, and how to safely reduce polypharmacy in clinical settings. Journal of the American Academy of Child & Adolescent Psychiatry 2016;55.doi:10.1016/j.jaac.2016.07.577
    21. ↵
      2. Thompson W ,
      3. Farrell B
      . Deprescribing: what is it and what does the evidence tell us? Can J Hosp Pharm 2013;66:201–2.doi:10.4212/cjhp.v66i3.1261
      OpenUrlPubMed
    22. ↵
      2. Jansen J ,
      3. Naganathan V ,
      4. Carter SM , et al
      . Too much medicine in older people? deprescribing through shared decision making. BMJ 2016;353.doi:10.1136/bmj.i2893
    23. ↵
      2. Pathirana T ,
      3. Clark J ,
      4. Moynihan R
      . Mapping the drivers of overdiagnosis to potential solutions. BMJ 2017;358.doi:10.1136/bmj.j3879
    24. ↵
      2. Anderson K ,
      3. Stowasser D ,
      4. Freeman C , et al
      . Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ Open 2014;4:e006544. doi:10.1136/bmjopen-2014-006544
    25. ↵
      2. Ailabouni NJ ,
      3. Nishtala PS ,
      4. Mangin D , et al
      . Challenges and Enablers of deprescribing: a general practitioner perspective. PLoS One 2016;11:e0151066. doi:10.1371/journal.pone.0151066
    26. ↵
      1. National Academy of an Aging Society
      . Public policy and aging report: comorbidity, deprescribing, and the healthcare of older people. The Gerentology Society of America, 2018.
    27. ↵
      2. Zito JA
      . Polypharmacy practice patterns: pharmacologic history supports the call for research on deprescribing protocols. Presented at the annual American Academy of Child and Adolescent Psychiatry (AACAP) conference, Chicago, IL, USA, 2019.
    28. ↵
      2. Bellonci C ,
      3. Huefner JC ,
      4. Griffith AK , et al
      . Concurrent reductions in psychotropic medication, assault, and physical restraint in two residential treatment programs for youth. Child Youth Serv Rev 2013;35:1773–9.doi:10.1016/j.childyouth.2013.08.007
      OpenUrl
    29. ↵
      2. Calarge CA ,
      3. Nicol G ,
      4. Schlechte JA , et al
      . Cardiometabolic outcomes in children and adolescents following discontinuation of long-term risperidone treatment. J Child Adolesc Psychopharmacol 2014;24:120–9.doi:10.1089/cap.2013.0126
      OpenUrl
    30. ↵
      2. Connor DF ,
      3. McLaughlin TJ
      . ANaturalistic study of medication reduction in a residential treatment setting. J Child Adolesc Psychopharmacol 2005;15:302–10.doi:10.1089/cap.2005.15.302
      OpenUrlCrossRefPubMed
    31. ↵
      2. Huefner JC ,
      3. Griffith AK ,
      4. Smith GL , et al
      . Reducing psychotropic medications in an intensive residential treatment center. J Child Fam Stud 2014;23:675–85.doi:10.1007/s10826-012-9628-7
      OpenUrl
    32. ↵
      2. Lindsay RL ,
      3. Leone S ,
      4. Aman MG
      . Discontinuation of risperidone and reversibility of weight gain in children with disruptive behavior disorders. Clin Pediatr 2004;43:437–44.doi:10.1177/000992280404300504
      OpenUrlCrossRefPubMed
    33. ↵
      2. Troost PW ,
      3. Lahuis BE ,
      4. Steenhuis M-P , et al
      . Long-Term effects of risperidone in children with autism spectrum disorders: a placebo discontinuation study. J Am Acad Child Adolesc Psychiatry 2005;44:1137–44.doi:10.1097/01.chi.0000177055.11229.76
      OpenUrlCrossRefPubMedWeb of Science
    34. ↵
      2. Lee TG ,
      3. Walker SC ,
      4. Bishop AS
      . The impact of psychiatric practice guidelines on medication costs and youth aggression in a juvenile justice residential treatment program. Psychiatr Serv 2016;67:214–20.doi:10.1176/appi.ps.201400544
      OpenUrl
    35. ↵
      2. Elliott R ,
      3. Fischer CT ,
      4. Rennie DL
      . Evolving guidelines for publication of qualitative research studies in psychology and related fields. Br J Clin Psychol 1999;38:215–29.doi:10.1348/014466599162782
      OpenUrlCrossRefPubMedWeb of Science
    36. ↵
      2. Seidel JV
      . Qualitative data analysis Colorado springs, 1998. http://www.qualisresearch.com/DownLoads/qda.pdf
    37. ↵
      2. Ulin PR ,
      3. Robinson ET ,
      4. Tolley EE
      . Qualitative methods in public health: a field guide for applied research. John Wiley & Sons, 2012.
    38. ↵
      1. Sociocultural Research Consultants, LLC
      . Dedoose version 8.0.35. Los Angelas, CA: Sociocultural Research Consultants, LLC, 2018.
    39. ↵
      2. Gupta S ,
      3. Cahill JD
      . A Prescription for “Deprescribing” in Psychiatry. Psychiatr Serv 2016;67:904–7.doi:10.1176/appi.ps.201500359
      OpenUrl
    40. ↵
      2. Gupta S ,
      3. Miller R
      . Deprescribing and its application to psychiatry. In: Steingard S , ed. Critical psychiatry. Switzerland: Springer, Cham, 2019: 137–53.
    41. ↵
      2. Reeve E ,
      3. To J ,
      4. Hendrix I , et al
      . Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging 2013;30:793–807.doi:10.1007/s40266-013-0106-8
      OpenUrlCrossRefPubMedWeb of Science
    42. ↵
      2. Hamrin V ,
      3. McCarthy EM ,
      4. Tyson V
      . Pediatric psychotropic medication initiation and adherence: a literature review based on social exchange theory. J Child Adolesc Psychiatr Nurs 2010;23:151–72.doi:10.1111/j.1744-6171.2010.00237.x
      OpenUrlCrossRefPubMed
    43. ↵
      2. Finkelstein JA ,
      3. Davis RL ,
      4. Dowell SF , et al
      . Reducing antibiotic use in children: a randomized trial in 12 practices. Pediatrics 2001;108:1–7.doi:10.1542/peds.108.1.1
      OpenUrlAbstract/FREE Full Text
    44. ↵
      2. Hu Y ,
      3. Walley J ,
      4. Chou R , et al
      . Interventions to reduce childhood antibiotic prescribing for upper respiratory infections: systematic review and meta-analysis. J Epidemiol Community Health 2016;70:1162–70.doi:10.1136/jech-2015-206543
      OpenUrlAbstract/FREE Full Text
    45. ↵
      1. Patient Centered Outcomes Research Institute
      . Comparing effects of state policies to monitor mental health medicines given to children in foster care, 2018. Available: https://www.pcori.org/research-results/2015/comparing-effects-state-policies-monitor-mental-health-medicines-given

    Footnotes

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available by contacting the first author.