Psychotropic Medication Use Among Foster Children
Description of the Problem
“Children under state protection in California group and foster homes are being drugged with potent, dangerous psychiatric medications, at times just to keep them obedient and docile for their overburdened caretakers” (Weber, T. (1998, p.1). While this may seem like a harsh statement to make, it raises valid concerns that individuals of the United States have. Additionally, numerous child welfare officials recognize the improper monitoring as one of the major parts of the problem of children in foster care being overmedicated with psychotropic medication.
Rates of children with emotional disturbances in state custody who are prescribed a psychotropic medication are increasing. Due to this, there are certain difficulties with this process in regards to consent and errors (Naylor, Davidson, Ortega-Piron, Gutierrez & Hall, 2007). Availability to medication evaluations can be difficult for children in care because of placement instability. Changes in placement decrease the probability of having a constant caregiver to participate in treatment of the child (Zima, Bussing, Crecelius, Kaufamn, & Belin, 1999).
Who is This Affecting?
Children and adolescents are a highly vulnerable population in the society of the United States, with foster children having an increased vulnerability level. Information gathered in 2008 showed that an estimated 463,000 children were in the care and custody of the state (Leslie et al., 2010). Children in foster care often have a large array of behavioral and developmental problems (Leslie et al., 2005). Sadly, more often than not, children in foster care have been sexually or physically abused and/or neglected which places them at an increased possibility of developing a mental health illness or behavioral and emotional disturbances (Naylor et al., 2007).
Children and adolescents in foster care utilize mental health services at an elevated rate in comparison to children who are eligible for Medicaid and are more apt to be prescribed psychotropic medications. The amount of psychotropic medications being used to treat children with severe behavioral and emotional disturbances has increased radically over the past several years. According to Zito et al., (2003), there was a two to three fold increase in the frequency of psychotropic medications being prescribed during 1987-1996. The medications that had the highest increase were Clonidine, anti-convulsant medications used to stabilize moods, and antipsychotic medication. (Naylor et al., 2007) Additionally, there was a 2.5-8 fold increase of polypharmacy which is recognized as using more than one psychotropic medication at the same time (Leslie et al., 2010).
In a study completed in 1999 by Zima et al. it was found that 13% of school-aged children who were placed in foster care had been prescribed psychotropic medication over the last year, with 52% of those children not receiving a medical evaluation within that year, despite it being necessary. Their sample included children ages 5-14 who were receiving Medicaid benefits. It was found that it was three times more likely that a child in foster care would receive psychotropic medication. Additionally, 13% of foster care children were prescribed psychotropic medication versus 5% of children found in a sample of elementary school students. However, they were not able to state that these statistics meant children were being excessively prescribed psychotropic medication due to the almost twice as high amount of diagnoses of ADHD and major depression in children in foster care. Five years later, results found in a study conducted by Breland-Noble et al.(2004) found that 67% of children in foster care were taking at least one psychotropic medication during the 4 month study period in addition to 77% of foster children in group homes taking a psychotropic medication (Breland-Noble et al., 2004).
Medication for Children
Of course important to note is that unless a medication is designed specifically to treat children, most medications are tested in adults first prior to the possibility of testing in children. Fairly often doctors prescribe medication for children and adolescents prior to research being carried out. The bulk of medication research in the United States is done by pharmaceutical companies. Many of these companies are tentative to sponsor studies for children which lead doctors to prescribe medications to children without having a preferred amount of research evidence (Crismon & Argo, 2009).
Naylor, et al., (2007) reported that the Physician’s Desk Reference, 60th edition from 2006 estimated that 45% of the medications prescribed for children and adolescents as means of treatment for emotional or behavioral disorders had not been approved for use with individuals under the age of 18 years old. Also, only 31% of psychotropic medications for treating disorders were commonly found in the child/adolescent age group. It’s fairly often that some medications used for psychiatric illnesses are only approved to treat medical disorders.
Foster parents, parents, clinicians, and other caregivers continue to be concerned about the doses of psychotropic medication prescribed to children due to the potential side effects, with the amount of side effects more common when the medication doses are increased (Crismon & Argo, 2009). There is not much research that is in support of polypharmacy, or prescribing more than one psychotropic medication to children aside from a report published supporting certain combinations of psychotropic medications. Even in that case, most of the combinations were open-label trials. There has not been any research results that support the wellbeing and efficiency of prescribing three or more psychotropic medications concomitantly (Naylor et al., 2007).
According to a recent report from Tufts Clinical and Translational Science Institute in 2010, the estimated use of psychotropic medication for children in foster care is much higher than those of the general child/adolescent population with foster children rates ranging from 13-52% and general population being 4%. More importantly, results showed that there is a large disparity in rates of medication use for youth in foster care across different geographic communities. There is therefore rising concern about the appropriate use (both over and under-use) of psychotropic medications for youth in foster care (Tufts University Health Sciences, 2010). On a more global scale, a report written by Child and Adolescent Psychiatry and Mental Health (2008) stated that children who live in the United States are an estimated three times more likely to be prescribed a psychotropic medication versus children living in Europe. Some reasons cited for the differences were the narrow practices and cultural beliefs about how medication plays a role in emotional and behavioral problems. Additionally, it was cited that the differences could be because of dissimilar diagnostic classification systems.
Description of the Current Policy/Law
The policy currently in place to address authorizing antipsychotic medication for children in Massachusetts’ state custody is the Rogers Process. While guardians can be appointed to an individual for various reasons such as medical, financial or property matters, the “Rogers” limits the guardian to make a decision about an individual with mental health and antipsychotic medication. In this process, a guardian is appointed by the Court and is given the responsibility of making decisions for an individual that was deemed incompetent to make informed decisions by a Judge (Department of Mental Health, 2011).
This process came about after a Massachusetts Supreme Judicial court case in 1983. The decision made was that individuals who were hospitalized in an inpatient setting had the right to refuse to take antipsychotic medications and make decisions about their treatment in non-emergency circumstances until that individual is deemed incompetent by a Judge. It is imperative that the Judge will decide an individual’s treatment by acting as a surrogate decision maker and use a “substituted judgment” standard. This standard is used so the Judge will make their decisions after taking the following factors into account:”a person’s expressed preference of treatment, their religious beliefs, impact on the family, side effects of the proposed treatment, and the prognosis with and without treatment.” (Department of Mental Health, 2011 p. 1)
It is a difficult decision for parents to make the decision, whether or not they want their child to take antipsychotic medication. However, when a child is in the custody of the Department of Children and Families (formerly known as the Department of Social Services) that decision is made by someone other than the child’s parent(s) (Office of Child Advocate, OCA examines, 2011). Even though many people are involved in the life of a foster child such as clinicians, lawyers, school staff, case worker, and Judges, there is not one sole person or “parent” making choices on behalf of the child in regards to their medical and mental care (Leslie et al., 2010).
How Does this Affect Foster Children?
The Rogers’ process was implemented by the Department of Children and Families in 1987 to make certain that foster children in state custody were receiving appropriate treatment to manage their medical, emotional, and behavioral needs. With this process, a guardian is appointed by the Juvenile Court to a child in the custody of the Department of Children and Families. The role of the guardian is to monitor the treatment plan that was previously identified and approved by the Court. Additionally, the guardian will monitor the child’s progress and report back to the Courts within the recognized time frames of that particular Court.
It is important to note that guardians are not able to approve or reject the use of antipsychotic medication for a child. They are able to examine medical records and talk to staff at any programs the child may attend or live at in addition to attending important meetings such as case conferences. As noted above, the guardian reports back to the Court on how things are going, and any concerns or worries can be presented to the Judge in an appropriate manner. At minimum, treatment plans need to be reviewed every year but this length of time can be changed by the Court to occur more frequently than annually if needed (Department of Mental Health, 2011).
Over the last estimated 23 years the make-up of the child welfare agency, children’s mental health treatment, and psychopharmacology has changed dramatically. Back in 2009, the Office of Child Advocate began discussions with professionals to discuss whether the Rogers’ Process was serving its proposed use. These discussions grew into what is known of as Rogers’ Working Group which consists of a group of policymakers and researchers. Movement and work began in the Summer of 2010 around evaluating the Rogers’ Process (Office of Child Advocate, 2011 revisiting). Currently, the Office of the Child Advocate (OCA) is working closely with Northeastern University School of Law and their students to examine the Rogers’ process in the state of Massachusetts.
The OCA is in the process of doing research and speaking with various individuals involved in this process such as Judges, lawyers, social workers, doctors, and any other individuals deemed necessary (Office of Child Advocate, 2011 Retrieved on 3/2/2011). The three key components included in this project consist of an analysis of the current legal framework of the Rogers Process, interviews with individuals involved with the Rogers process, and a comparison of other states’ protocols for attaining informed consent for children in foster care. This research projects expected time of completion is slotted to be May 2011 (Office of Child Advocate, 2011 revisiting).
Analysis and Evaluation of the Policy/Law
While I believe the Rogers Process was a step in the right direction for the child protection agency of Massachusetts, I feel there is great room for growth and improvement. While I can’t speak on the complete Rogers process, I have concerns just by observing what I see in the Juvenile Court rooms through my work at the Department of Children and Families. While the length of time spent on discussing the child’s progress and treatment has improved with a new Judge sitting on our bench, I’ve seen other Judges not appear to read through the report. I’ve often witnessed less than a 5 minute conversation about the child before an increase is approved with the update consisting mostly of how the child is doing. While I hope that report is very detailed and has numerous people’s input, it’s rare that I have seen the Judge sit and read the report prior to ruling. I can’t say for certain this isn’t happening, but this has been my general observation. While the Rogers’ Process covers antipsychotic medication, consent from the court is not needed for other psychotropic medications (Naylor et al., 2007).
A multi-state study was completed by Tufts in 2010 to research psychotropic medication and youth in foster care. The study results expressed concern with the inconsistency among state policies and practices around psychotropic medication for foster children and potential oversight. The study recommended a national approach to deal with the issue of medication mistakes for children in foster care. Their concern is that if a national policy or practice isn’t implemented, then a children moving from one state to the next makes a difference as to whether they are appropriately medicated or not.
Criteria for Judging Alternative Policy/Law
A newspaper article in the Los Angeles Times written by Tracy Weber (1998) spoke to me as many of the criteria I felt needed to be included in a new or revamped policy for prescribing psychotropic medication to children in foster care were included in people’s concerns. First, I will discuss the shared and reported concerns from numerous case managers or prescribers in California expressed in the article then I will outline my criteria for the policy. Despite an 8 year old law, at the time this article was written, that requires foster children have medical passports which documents all medical appointments, illnesses, and medications that will follow them from their placement(s), there is worry that this expectation is ignored. Reasons cited by officials is that it could be due to it being tedious and time consuming which leaves many children’s medical passports incomplete. Dr. Kenneth Steinhoff, UC Irvine’s chief of child psychiatry expressed concern that he often doesn’t know what medications a child has previously been on due to not receiving an appropriate and complete medical history (Weber, 1998).
Also, the missing puzzle piece for many children in foster care is having someone in the parental role as they are not in the care or custody of their biological parents. According to the newspaper article, some of these foster parents were believed to put their foster children on medication without taking the appropriate measures of evaluations and obtaining consent. Concerns were noted that the wrong message is being sent to foster children who are placed on psychotropic medication. Dr. Thomas Laughren, medical reviewer for the FDA’s division of neuro-pharmacological drugs, believes that “you’re teaching them that they’re dependents and damaged and need drugs to be normal (Weber, 1998., p. 4). Also, it sends the message that if you take this pill you will feel better (Weber, 1998).
Upon reviewing the current policy in place for prescribing antipsychotic medication for children in foster care in Massachusetts, I created a report card of several criteria that I believe are necessary to ensure foster children are being appropriately medicated and monitored. The criteria includes a detailed psychosocial assessment of the child prior to prescribing psychotropic medication, frequency of medication checks, 2nd opinion and/or second eye on medications prescribed, detailed and comprehensive medical information to be available to prescribers and clinicians, ensuring medication prescribed is in addition to and in relation to treatment plans and diagnosis, and appropriate consent. The two policies I am going to consider as an alternative policy for psychotropic medication for foster children in Massachusetts are from the state of Illinois and Oregon. Below are their report cards. The grades were given based on how well and how closely they met the criteria. I gave a grade of “A” if the policy successfully completed the relevant criteria and a grade of “F” was given if the policy did not address the criteria. Grades of “B”, “C”, & “D” will be given if the policy is somewhat addressing or meeting the criteria but there is a call for improvement.
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The policy currently in place in Illinois scored fairly well against my six criteria. I gave them a “B” on the first criteria as the policy does state that a child has to receive a diagnostic assessment prior to being prescribed a psychotropic medication. However, I feel it is important for the prescriber to obtain additional information that would be on a psychosocial assessment as a child’s personal and familial history is vital knowledge for a clinician to have to be able to move forward with their treatment with the child. In regards to the second criteria, the grade given was an “A” as they see the importance of monitoring the medications closely. The frequency of the visits depends on what is being prescribed and where the child is in the treatment phase (initiation, acute, continuation, maintenance, and discontinuation phase). A grade of “C” was reserved for the 3rd criteria as it’s outlined that prescribers should be able to back up their reasoning for the medication(s) they are prescribing to a child. I didn’t feel it warranted an “A” as the medication checks don’t take place over a consistent amount of time (Illinois Department of Children and Family Services, 2010).
An “A” was given for the 4th criteria as communication between all clinicians involved in the child’s care needs to occur and needs to be documented. Medications that are prescribed to children need to be in concurrence with their diagnosis, symptoms, and treatment plan which earned Illinois an “A” on the 5th criteria. They received the same grade for the 6th criteria as they established the Centralized Psychotropic Medication Consent Program out of the office of the Guardian to ensure appropriate consent is provided to children in foster care prescribed psychotropic medication. Furthermore, they have contracted with the University of Chicago to have reviews of all consent requests from clinicians who wish to prescribe a psychotropic medication(s) for children in foster care (Illinois Department of Children and Family Services, 2010).
The policy for the state of Oregon did not do as well against my criteria. On the first criteria they received a “C” because a complete mental health assessment only needs to be completed prior to prescribing more than one psychotropic medication or an antipsychotic medication. A “B” was given for the second criteria because while they have annual reviews of medications by a licensed medical professional in addition to the prescriber. I feel as though reviews of medications should take place more consistently, possibly every 6 months as a child’s situation, progress, and symptoms may change or improve. The above reasoning is why a “B+” was given for the 3rd criteria as they meet the criteria but I feel the time frames could be shortened to ensure the second opinions are utilized more frequently (Oregon Legislative Assembly, 2009).
Oregon’s policy received a “F” for the fourth and fifth criteria as there is no documentation of either of those things being included in the bill. I gave them an “A” on the last criteria as Oregon has created a very detailed and well thought out consent process flow chart. To give a brief outline, the foster parent is properly educated on the child’s mental health situation. When a child in foster care sees a prescriber consent forms are filled out and sent to the appropriate branch personnel. Upon the caseworker receiving the paperwork, they complete the necessary sections and send it to a program manager who completes the final section. At that point consent is granted or denied. If consent is granted then the signed consent is sent back to the prescriber and the medication is filled and given to the child. If more information is needed prior to giving consent, the prescriber or nurse manager can be contacted. If consent is denied then the proper protocols will take place (Oregon Legislative Assembly, 2009).
After examining other policies in place to ensure proper consent and prescribing of psychotropic medication for children in foster care in Oregon and Illinois, I feel that the current policy implemented by Illinois will better serve children in foster care. While Oregon has some positive attributes to their policy, there are more missing pieces as evident by the report card I gave them against my recognized criteria. The policy currently in place in Illinois scored reasonably well against the six criteria I outlined. Despite them scoring well there is room for improvement which I will further summarize.
Illinois acknowledges sees the significance of monitoring psychotropic medications closely. The frequency of the visits depend on what is being prescribed and what treatment phase the child is in as certain phases warrant closer monitoring than others. They also see the importance of communications between all clinicians and caretakers involved in the foster child’s life, with this communication needing to be documented. It’s also very important to ensure the medication prescribed is related to the child’s diagnosis and the symptoms they are exhibiting in addition to the recognized treatment plan. There was a new consent program, Centralized Psychotropic Medication Consent Program, created out of the office of Guardian to make certain that proper consent is granted to foster children taking psychotropic medication. Additionally, they contract with the University of Chicago to have the requests from clinicians to obtain consent for foster children reviewed to ensure proper steps are taken (Illinois Department of Children and Family Services, 2010).
Despite my recommending this policy, it is important to note parts of the policy that there is room for improvement. While a diagnostic assessment is needed prior to a child being prescribed a psychotropic medication, a more detailed assessment to include familial and personal history would be beneficial. This would allow the prescriber to have a better idea of the child’s past and current functioning as trauma can often manifest itself in symptoms of diagnosed mental illness. More consistent medication checks need to take place under this policy as it only states that prescribers should be able to substantiate the medications they are prescribing and for what purpose. It appears that the only time this could be reviewed is if a review was called for (Illinois Department of Children and Family Services, 2010).
I think it’s vital for the children in foster care in Massachusetts to have the current policy, the Rogers’ Process updated and revamped to ensure foster children are being appropriately medicated and monitored. A lot of new information will come from the current research being conducted to learn if the Rogers’ Process is currently working in Massachusetts. I’m hopeful that changes and improvements will be implemented following the conclusion of the current research upon which recommendations will be made. At minimum, the current policy in place in Massachusetts needs to expand to include all psychotropic medications, not just anti-psychotic medications. I can foresee the state of Massachusetts looking at other policies upon expanding and improving the current policy. I recommend the policy of Illinois be strongly considered as an alternative policy to utilize in place of the Rogers’ or to consider adding Illinois’ criteria to the current policy in place in Massachusetts.
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