More than a fifth of Pennsylvania's foster children in 2012 were taking antipsychotics, powerful medications that can cause serious metabolic side effects, including rapid weight gain and diabetes. Yet most of them had not been found to have conditions proven to respond to such drugs, a study released Tuesday found.

While the use of psychiatric drugs has declined slightly among Pennsylvania children on Medicaid, the study found that it remains high, especially among foster children.

Children ages 6 to 18 in foster care were almost three times more likely in 2012 than others on Medicaid to take psychotropic medications - those used to manage mental health or behavioral symptoms - and four times more likely to take antipsychotics.

Of particular concern was that 56 percent of children on Medicaid taking antipsychotics were taking them off-label. Thirty-six percent had attention deficit hyperactivity disorder (ADHD), for example, but no record of psychosis.

"We think that's unacceptable," said Ted Dallas, secretary of the state's Department of Human Services, which oversees Medicaid, the health insurance program for the poor. He spoke at a news conference Tuesday morning at Children's Hospital of Philadelphia.

The report was produced by researchers at Children's PolicyLab, who have been studying psychotropic drug use in this population for several years. The overuse of these drugs in low-income children is a national issue that has gotten the attention of federal and state officials.

David Rubin, codirector of PolicyLab, and his colleagues called for expansion of nondrug treatments such as therapies proven to help children with violent or aggressive behavior. While access to such counseling has been growing, he said, doctors may sometimes feel "medication is the only tool in the toolbox."

In response to PolicyLab recommendations, the state vowed to improve assessments for children with behavioral issues, expand drug preauthorization requirements to managed care plans, improve training for adults who care for foster children, and create a telephone psychiatric consultation service.

Asked if children have adequate access to therapy, Cathy Utz, deputy secretary for the Office of Children, Youth and Families, said, "I think that it varies." She said the department was looking at how to expand resources.

In 2012, the last year covered by the report, there were 718,500 Pennsylvania children ages 3 to 18 on Medicaid. Of those, 18,400 were in foster care.

PolicyLab found that 16 percent of all 6- to 18-year-olds in Medicaid were prescribed psychiatric drugs in 2012, compared with 43 percent of children in foster care. Twenty-two percent of foster children took antipsychotics, compared with 5 percent in the Medicaid program. More than half of the Medicaid antipsychotic users had been found to have ADHD. The FDA has approved use of the drugs for bipolar disorder, schizophrenia, and aggressive behavior associated with autism and intellectual disability, the report said. Most of the users with ADHD did not have any of those diagnoses.

Twelve percent of foster children were taking multiple psychiatric drugs.

Dallas said foster children experience trauma in the form of abuse and neglect, and are traumatized again when they are removed from the only homes they have known.

"To think that we're compounding that damage by inappropriately prescribing medications to these kids is deeply disturbing," he said.

Dallas said he did not have a goal for how much psychiatric drug use should come down, but said the gap between foster children and other low-income kids should be smaller.

Meredith Matone, a research scientist who worked on the report, said antipsychotics improve problem behavior that can put children's foster placements at risk. "Antipsychotics have sedative properties for controlling aggressive behavior," she said.

But the Children's researchers said the drugs do not address the root causes of the behavior.

"A lot of times, what is being treated with the medication is a behavioral manifestation of trauma exposure," Matone said.

Stephen Crystal, a Rutgers University health services expert who has studied the issue, said that children on Medicaid had higher rates of behavioral problems than those with private insurance, and that children in foster care were even more likely to need mental health care than the general Medicaid population.

He said professionals often try to stabilize children quickly. Many children may not have quick access to the psychosocial interventions that he thinks should be the "first resort." Medication, he said, should be the last resort.

States that have done a better job of "encouraging judicious prescribing" have brought their antipsychotic drug rates in foster kids down to "a lot lower than 22 percent," he said.