Geographic variations in service utilization have emerged as sentinels of quality of care. We used data from the National Survey of Child and Adolescent Well-Being (NSCAW), the Kaiser Family Foundation, and the Area Resource File to examine interstate variations in psychotropic medication use among children coming into contact with child welfare agencies. Mean probabilities of medication use differed by 13% between California (7.1%) and Texas (20.1%). On regression analyses, children in California had a fifth of the odds of medication use compared to children in Texas, principally, because child characteristics of age, gender, foster care placement, and mental health need seem to be evaluated differently in Texas compared to in other states. These findings suggest that interstate variations in psychotropic medication use are driven by child characteristics, rather than by mental health need. Understanding the clinical contexts of psychotropic medication use is necessary to assure high-quality care for these children.