Medicaid programs have experienced considerable growth in antipsychotic prescribing, particularly of second-generation antipsychotic agents. As the use of antipsychotic medications has grown, so too has evidence about the effectiveness, appropriateness, and safety of these treatments in pediatric populations. A major concern is metabolic abnormalities, which have been shown to be poorly monitored for children who take antipsychotics. Combined with concerns regarding antipsychotic use for conditions where there is limited long-term evidence-based support, many Medicaid programs have restricted antipsychotic utilization in the pediatric population. Restrictive policies, such as prior-authorization requirements, may reduce spending for antipsychotic treatment but may also present a barrier to patients who need antipsychotic treatment for approved purposes, restrict provider choice of treatment, and fail to address issues of safety, including metabolic monitoring.