The Financial and Societal Costs of Medicating America's Foster Children

A Senate hearing was held yesterday, "The Financial and Societal Costs of Medicating America’s Foster Children."

Mr. Bryan Samuels, Commissioner, Administration on Children, Youth and Families, U.S. Department of Health and Human Services, gave the following testimony: "During my tenure as Director, DCFS developed a comprehensive system of protocols and safeties to ensure that psychotropic medications are prescribed responsibly and monitored consistently."

This included:

• Requiring that all prescriptions be reviewed and approved at the State Deputy Director level; 

• Establishing time-limits for reviews to ensure that necessary treatment was not delayed;   

• Developing an electronic database for tracking all prescriptions for children in foster care;

• Creating “red flags” in the database that elevated certain cases, such as those in which three or more medications were prescribed, for more thorough review; and

• Establishing best practice guidelines and distributing them to prescribers. The electronic database was also designed to identify providers whose patterns of prescribing differed from the guidelines.

Here’s the link to learn more: http://hsgac.senate.gov/public/index.cfm?FuseAction=Hearings.Hearing&Hearing_id=9fc194de-2a7c-4417-8f2b-6b90cadacede

Drugging Foster Youth - Influence of Pharmaceutical Companies

Quotes from Time Magazine article: Szalavitz, Maia. Why Are So Many Foster Care Children Taking Antipsychotics?Time Magazine, November 29, 2011 .

• "The influence of pharmaceutical company marketing cannot be overlooked. Ninety-nine percent of youth receiving anti-psychotic medications in the study were given atypical anti-psychotics — the newer generation of these drugs, which are expensive and mostly unavailable in generic form and have been heavily advertised .

• "All of the major manufacturers of these drugs have been fined by the Food and Drug Administration for illegal marketing practices — in part, for marketing the drugs for unapproved use in children — with some convicted of criminal charges.

• " The main condition that antipsychotics are approved to treat —schizophrenia — is extremely rare in children . The rate of schizophrenia in children under 12 is an estimated 2 cases per 1 million children; it affects fewer than 1% of older teens. Anti-psychotics are also approved to treat bipolar disorder, a diagnosis that is highly controversial in children . Some studies suggest that it affects 0.2% to 0.4 % of children, and up to 1% of adolescents.

• And yet, between 1994 and 2003, rates of bipolar diagnoses in youth under 19 rose by a factor of more than 40, according to the National Institute on Mental Health. It seems unlikely to be a coincidence that this rise occurred during the period when atypical anti-psychotics were being illegally marketed for children ."

• "Indeed, most of the anti-psychotics used in foster-care youth were for conditions that the drugs were not approved to treat . Fifty-three percent of prescriptions were written for attention deficit/hyperactivity disorder (ADHD), a condition that is ordinarily managed with drugs that have the opposite pharmacological effects as anti-psychotics. The stimulant medications like Adderall and Ritalin, widely used for ADHD, tend to increase levels of dopamine, while anti-psychotics tend to decrease it."      

Unnecessarily Drugging Foster Care Youth

A concern that comes up again and again with foster care youth and young adults is the issue of overmedication in foster care.

 

A new study, Antipsychotic Treatment Among Youth in Foster Care , examined concomitant antipsychotic use among Medicaid-enrolled youth in foster care, compared with disabled or low-income Medicaid-enrolled youth.

They found that:

• More than a third of youth in foster care without disabilities had multiple anit-psychotic prescriptions lasting longer than 90 days
• Children who were not adopted had the highest rates of prescriptions, representing 38 out of every 100 children in foster care.

In comparison, 26 out of every 100 children who were on public assistance but not in foster care had more than one antipsychotic prescription.

In recent years, doctors and policy makers have grown concerned about high rates of overall psychiatric drug use in the foster care system. Previous studies have found that children in foster care receive psychiatric medications at about twice the rate among children outside the system. 

In 2008, the House Ways and Means Subcommittee on Income Security and Family Support held a hearing on the u tilization of psychotropic medication for children in foster car e.

In 2010, Senator Daniel Akaka (D-HI) asked the Government Accountability Office (GAO) to investigate the prevalence of prescribed psychotropic medications for children in foster care.    

Continued Concerns Regarding Psychotropic Drugging of Foster Care Youth

According to the Multi-State Study on Psychotropic Medication Oversight in Foster Care conducted by the Tufts Clinical and Translational Science Institute:

• The use of psychotropic medications for foster children between the ages of 2 and 21 has risen significantly over the past decade.

• Out of the forty-seven of the 50 U.S. states and the District of Columbia participated in this study, nine states had no written policy/guidelines regarding psychotropic medication use for foster youth.

Read the report to learn more about challenges faced by states, and innovative initiatives that some states have implemented in order to address this issue.

Psychotropic Meds for Youth in Foster Care: Who Decides?

Dated January 5, 2011, and authored by the Georgia Supreme Court Committee on Justice for Children, this report makes vital recommendations:

1. Georgia needs to obtain accurate information about psychotropic medications and youth in foster care, including how many youth of what ages are receiving which medications for what purposes and at what costs.
2. Georgia needs to develop guidelines for the use of psychotropic medications for youth in foster care.
3. Georgia needs to develop a clear process for obtaining informed consent for the administration of psychotropic medications to youth in foster care. The process needs to be specific about who has authority to consent for a youth in foster care.
4. Georgia should develop one or more independent clinical teams that include a board-certified child psychiatrist to provide the following services:
   • individual case consultation to the state agency and prescribers;
   • training for those who work with youth in foster care;
   • independent review of all prescriptions for psychotropic medications that are written for youth in foster care before the prescription can be filled.
5. Youth in foster care should have a comprehensive mental health treatment plan that includes consideration of a variety of interventions and treatments that may include medications.
6. Georgia needs to establish quality assurance mechanisms to continuously improve all systems serving the mental health needs of youth in foster care and to hold all parts of the systems accountable.
7. The court system should help raise awareness about psychotropic drugs and youth in foster care.

What I like best about this report is how it describes the level of responsibility that the state has for young people in foster care:


"The state of Georgia has the awesome responsibility

of serving as parent for some 7500 children in foster care."

Serving as a parent implies: Knowing what prescriptions have been prescribed, why they have been prescribed, what the side-effects are, what the long-term treatment plan is -- and not hesitating to advocate if the medication appears to be more harmful than helpful.

For Oregon foster children, the psychotropic drugs are plentiful, but mental health services are few

Dr. Walter Shaffer, medical director for Oregon's medical assistance programs testified before the Senate Health and Human Services that:

*Between Jan. 1, 2004, and Dec. 31, 2006, children in the Oregon foster care system were three times more likely than other children to have been prescribed a psychiatric drug.

*Over that two-year period, nearly 4,700 Oregon foster children were prescribed an antidepressant, stimulant or other mood stabilizer.

*Meanwhile, less than a third of them received mental health assessments within 60 days as the law requires.

While the pharmaceutical industry might benefit from this all-too-common lack of oversight, it endangers the lives of these children.

As a former foster child and current youth advocate, I agree with Shaffer's recommendation that the state should:

1.) Hire a medical director for child welfare
2.) Build a network of nurses or mental health experts to consult with caseworkers
3.) Develop a better data system to track psychiatric medications used by children in foster care

It is important to note that this is a national problem, and it needs to be addressed. If the government is 'parenting' these children, then the government is accountable to regulate their medication, just as a parent would.

It is a crime when state laws are ignored, and hundreds of foster children prescribed multiple prescriptions with little or no state scrutiny.

Why? Because young children are three times as likely as adults to have adverse results to psychotropic drugs.

Drastic, damaging side effects can haunt their adulthood, as a result of this negligence, including lifelong medical problems and the inability to have children of their own.

Source:
Cole, Michelle. Testimony reveals foster care failings. Oregonian, Feb. 14, 2008.

Tristen says, Don't drug me for being sad. I lost my family.

California bill proposed to regulate psychiatric drugging of foster children

http://californiafostercarenews.blogspot.com/2007/03/trauma-of-foster-care-should-not-be.html

Come on, Rebecca, it's time for your "happy pills"

Photo of Rebecca Riley from msnbc.com

Does this little girl look like she needed to be on antipsychotic drugs to you?

Yes, her parents actually referred to the psychotropic meds as "happy medicine" and "sleepy medicine."

Accountabilty for overmedicating children

Photograph of Rebecca's parents, Michael and Rebecca Riley from the Boston Globe.

In Hull, Massachusetts, Rebecca Riley perished from an overdose of prescription drugs.

Was it an accident? Did she sneak into the medicine cabinet?

No, her doctor prescribed the drugs, and her parents gave them to her, just as they also doled out similar drugs to her 6-year-old sister and 11-year-old brother.

Here are the drugs that four-year-old Rebecca was prescribed:

1.) Seroquel, an antipsychotic drug
2.) Depakote, a mood stabilizing drug
3.) Clonidin, a blood pressure medication often prescribed for ADHD

These drugs are approved by the FDA for adult use only - yet doctors frequently prescribe them for children.

When parents overmedicate their four-year-old child with psychotropic drugs and kill her, we are shocked. We want them to be held accountable. Because of this, Rebecca's parents are being prosecuted for murder.

Let's not overlook the other entitities that should be held accountable for unnecessarily drugging children...

1.) If the government is "parenting" foster children, then it should be held to the same standard as Rebecca Riley's parents.

In the foster care system, 3-year-olds are given anti-schizophrenic medication. Six-year-olds are taking Prozac. Nine-year-olds are being prescribed four psychotropic medications at the same time.

Poor record-keeping masks the scope of this problem. But recent CBS research into Los Angeles group homes for foster children uncovered evidence of teenagers being medicated without court intervention, and with minimal doctor oversight. As one social worker reported to CBS, "It's just a chemical restraint. We don't know what else to do with you."

Former foster children report overmedication during their time in the system. Trayvon Walker reports, "In one day, I would say (I was given) probably 20 different medications. I was on Depakote, Wellbutrin, Triptal, Clonidin, Dispar." (Do these drugs seem familiar? Two of them were also prescribed to Rebecca, above).

What was the outcome of these drugs on Trayvon's health? It caused him to have kidney renal failure.

2.) Insurance companies contribute to this problem, because they are often more willing to pay for drugs than therapy. Phamaceutical and managed care companies benefit financially from prescribing lots of drugs to foster children. So do group homes.

3.) Shouldn't medical practioners be held accountable for overmedicating children and teenagers?

Regarding Rebecca's untimely death, Dr. Kayoko Kifuji has taken a leave of absence until the case has been resolved. The medical establishment where Rebecca was treated, Tufts-New England Medical Center has issued a statement saying that they support Dr. Kifuji and her decisions.

Doctors of conscience, however, are speaking out about this issue.

*Dr. Bessel van der Kolk, a professor of psychiatry at Boston University who runs a trauma clinic said, "Most of the patients I see who have been misdiagnosed have been told that they have bipolar disorder."

He continued, "This diagnosis is made with no understanding of the context of their life. Then they're put on these devastating medications and condemned to life as a psychiatry patient."

*Child psychiatrist Joseph Penn of Brown University Medical School expressed his dismay at the practice of "polypharmacy" with children:

When one drug causes side effects in children, they are often given another drug to deal with the side effects. If stimulants cause insomnia, the child is given sleeping pills - despite the fact that safety tests have not been done to measure the effects these drugs have on children, both alone and (especially) in conjunction with other drugs.

Sources:
Child's death raises concerns about psychiatric drugs. CNN, March 23, 2007.
Cramer, Maria and Raja Mishra. Girl fed fatal overdose, court told. Parents arraigned; lawyer questions doctor's role. Boston Globe, Feb. 7, 2007.
Elias, Marilyn. More kids get multiple psychiatric drugs. USA Today, Aug. 1, 2005.
Goldstein, David. Foster kids medicated for money? CBS, Nov. 13, 2006.
Higgins, Gary. Debate over children and psychiatric drugs. New York Times, Feb. 15, 2007.
States wrestle with medicating foster kids; Critics worry that psychiatric drugs flow too frequently to forgotten children. MSNBC, March 13, 2007.

More on Overmedicating Texas Foster Children

Newscast about overmedicated foster children in Texas

Online newscast on foster children & antipsychotic drug

http://www.cbsnews.com/sections/i_video/main500251.shtml?source=RSS&attr=CBSNewsVideo_2104407&channel=i_video&id=2104407n

With the link above, you can view Byron Pitt's interview with Gwen Olsen, a pharmaceutical representive who has worked in the foster care system as a CASA. She was familiar with the side effects and dangers of these products, and therefore was greatly concerned.

Olsen reports that children ages 2, 3 4 and 5 years old are receiving major antipsychotic drugs... often for "off-label" indications such as sleep disorders or behavioral disorders.

Young children are three times as likely as adults to have adverse results to psychotropic drugs. They cannot metabolize or eliminate the drugs, so these drugs become neurotoxic in their system, and pass through the blood-brain barrier.

Long-term clinical data indicates that "artificial behavioral improvements" deminish over time. In fact, children often manifest symptoms from previous drugs.

When psychotropic drugs become neurotoxic, physicians should withdraw drugs -- not add another drug.

Olsen alleges that prescriptions are motivated in part by financial gains by the pharmaceutical industry.

Strengthening state oversight over pyschotropic drug prescriptions for foster youth

States should diligently monitor the usage of psychotropic medication

In 2003, the Miami Herald reported that the Florida Statewide Advocacy Council had conducted a two-year investigation of 1,180 foster children, and found that over 50% had been presribed mind-altering drugs. This included 17 preschoolers.

These drugs had not been approved by the FDA for use by children.

At the time, Florida's Medicaid office was surprised by the number of children who were prescribed psychotropic medications without a psychiatric diagnosis.

- 44% of foster youth had not been seen by a doctor.

- 38% of the children studied were given drugs without signed consent from a parent, guardian or judge, as state law requires.

- 89% of foster children on psychotropic drugs had no records in their file to show they were being medically monitored.

Richard Wexler, head of the National Coalition for Child Protection Reform. commented, "This is child abuse on a grand scale. It's obvious that DCF still hasn't learned to just say no to drugs.''

Florida legislators passed a law over a year ago, to curb the usage of psychotropic drugs by Florida foster children.

Yet today , according to the Miami Herald, state welfare officials still do not have an accurate list of foster youth who are currently being given such drugs.

Patricia Badland, head of Florida's family safety program, recently reported that Florida caseworkers have failed to monitor foster youth who have been prescribed anti-depressants, anti-psychotics and other drugs designed to combat mental illness. Most of these drugs have never been tested on children.

Badland is particularly concerned about children under the age of six years old, who have been prescribed "a psychiatric cocktail" of drugs.

Sources
Miller, Carol Marbin. Mind-altering drugs given to some babies in DCF's Miami Herald, Sept 17, 2002 p. A-1
Miller, Carol Marbin. No list of kids on mood drugs. Miami Herald, Sept. 23, 2006, Metro pg. 1B.

Drugging Foster Children

If I hadn't read these articles, I (a former foster child) would have thought that drugging foster children was an urban legend.

It is the stuff of a science fiction novel:
-States such as Texas, Florida and Minnesota discover an alarming number of foster youth on behavior-altering drugs.

-California state regulations provide financial incentive for group home staff to request and administer psychotropic drugs to children in their care -- because rates are based on mental-health treatment services per child.

-A seventeen-year old foster child in California is threatened that if she doesn't take the drugs she was prescribed, she will not receive transitional housing.

Unfortunately, all these things are happening - and it is time for them to stop.

Medicating wounds, rather than healing them
Medications have their place in helping members of society. But foster youth who experience grief, fear and sadness are simply displaying normal reactions to their living situations.

Consider this scenario:
Girl's mother dies - Girl feels sad - Staff recommends Zoloft - Group home receives more money.

What's wrong with this picture? It creates a system that is ripe for abuse.

In Texas, 12,000 foster youth received psychotropic drugs in 2004. Each child averaged 21 psychotropic drug prescriptions a year.

In Massachusetts, two-thirds of 17-year-old foster children have recieved inpatient or outpatient medical treatment (as opposed to only 37% in Illinois, Iowa and Wisconsin). State Representative Marie Parente believes that state reimbursement checks from the federal government might be a financial incentive to misdiagnose and overmedicate foster children.

In California, the use of drugs remains unchecked and unregulated. The California Psychiatric Assocation blocked the passing of a 2004 bill by then-Senator Mountjoy to analyze the administration of drugs to children in foster care.

Judges approving dosages
According to the California rules of court, Rule 1432.5: "Once a child is declared a dependent child of the court and is removed from the custody of parents or guardian, only a juvenile court judicial officer is authorized to make orders regarding the administration of psychotropic medicine to the child."

Is the judge now considered a medical expert? Does he or she even meet the child in question? Often, all that judge has to go by are the reports handed in by social workers and group home staff.

In 1999, when Governor Gray Davis gave final approval to the law requiring judges to sign off on medication requests, many juvenile judges said that they didn't know much about medications, nor the doctors prescribing them.

One judge reported that he simply trusted that the 'doctor knows best.' While Los Angeles Juvenile Court had the funding to screen requests through the county's medical health unit, other judges lacked the money for such a review.

Also, according to California rules of court: "In emergency situations, psychotropic medications may be administered to a dependent with or without court authorization..."

This is both disturbing and vague.

What constitutes an emergency situation? Is it only that the child is sad, and the group home will recieve more money? California group homes receive anywhere between $2000 and $6000 per foster youth, depending on what medications they are on, according to Jennifer Rodriguez, legal representative for the California Youth Connection.

Foster youth are not informed of their right to refuse medication. Foster youth reported being punished for refusal by losing privilges and threatened that they will be evicted from the group home.

Risks of overmedicating
Attorney Andrea Moore, of Florida, is currently representing several children who began lactating after taking antipsychotics .

One of her clients is also a twelve-year-old whose heart condition was exacerbated by the Geodon she had been prescribed. According to Moore, the doctor who prescribed Geodon did not even have the child's medical history. The drug's label clearly states that patients with heart problems shouldn't take it.

Actions being taken in California:
-Assembly members Noreeen Evans and Karen Bass, both members of the Select Committee on Foster Care, have requested a public hearing in August, focusing on medication, foster care and the lack of communication (and accountability).

-Attorney General Bill Lockyer is investigating the amount of tax dollars being spent to overmedicate foster youth.

-State Comptroller Steve Westly has called upon Governor Schwartznegger to take immediate action on this issue "in order to ensure that no one profits by forcing kids to take mind-altering drugs."

Nationwide concern
Paul Vincent, of the Child Welfare and Policy Group, believes that the number of foster children being prescribed antipsychotics has risen over the past few years.

Children as young as four-years-old are being prescribed antipsychotics. And, who is doing the prescribing? Vincent says, "They aren't even psychiatrists or counselors. I have considerable worry over the accuracy of these diagnoses."

According to USA Today:
-There was a 77% increase in Med-Cal prescription claims in California between 2001-2005.

-Illinois had a 39% increase betwen 2003-2005.

-In Florida, the number of Medicaid children taking antidepressants jumped from 9,500 to 17, 000 over the past five years.

Sources:
For foster kids, oversight of prescriptions is scarce. USA TODAY. McLean, Va.:May 2, 2006. p. D2

Hayasaki, Erika. Teens speak out about foster care; Thirty young people attend a summit at Occidental College to tell policymakers about problems they face and suggest some solutions. Los Angeles Times Los Angeles, Calif.:Jun 6, 2006. p. B2

To our children's defense. San Francisco Chronicle San Francisco, Calif.:Jun 14, 2006. p. B8

Vascellero, Jessica. Prevalence of drugs for DSS wards questioned. Boston Globe Boston, Mass.:Aug 9, 2004. p. B1

Weber, Tracy. California and the west: Foster children on medication get protections; Health: Davis signs measure to prevent youths in state care from getting improper or unmonitored doses of psychiatric drugs. Los Angeles Times Los Angeles, Calif.:Sep 30, 1999. p. 3