What If Every State Had Foster Care Medical Review Panel?

What if every state had a Foster Care Medical Review Panel, serving in a role similar to a Medical Ombudsman, that foster care youth, alumni, foster parents, CASA/GAL, etc. could contact with  concerns about over-medication?   


Forgotten Children A Special Report on the Texas Foster Care System Comptroller Carole Keeton Strayhorn (April 2004)

Findings

• DPRS exercised little meaningful oversight over the treatment of foster children with psychotropic medications.

• No formal investigation related to psychotropic medications had ever been conducted.

• YFT did not attempt to assess the appropriateness of medications.

• Many foster children were being prescribed psychotropic medications by physicians who were not trained in child psychiatry.

• Even though federal law requires a foster child’s medical records to be reviewed, updated and given to foster care providers, foster care providers of 46% children in a study conducted by the OIG never received medical histories of the children in care, including children with serious medical conditions.   Without access to a child’s medical records, it was difficult for foster parents to effectively care for foster children.

Challenges Noted:

The Advisory Committee recognized that “[c]oncerns exist regarding the inappropriate use of psychotropic medication and inadequate monitoring of prescribed medications.  


There was also a lack of data available regarding physician prescribing practices and child outcomes.  Children in foster care may be subject to widely varied standards of care.  There is currently no way to monitor the quality of care and no system for resolving concerns associated with the use of psychotropic medication for children. 


Also there is no method for “second” opinions to be easily obtained by DFPS staff when they have concerns or questions.”

In response, their plan was to:

• Develop review panels of medical professionals including (trauma-informed) child psychiatrists to provide recommendations regarding care for foster children where there is a question on whether their care is clinically appropriate.

• Establish clinical guidelines and protocols for psychotropic medications and a review process for identifying children’s medical records that fall outside the guidelines and reviewing them for inquiry or possible corrective action.

• Develop a medical and educational passport for each child that follows the child through placement changes and is readily available to healthcare providers and schools electronically.

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.

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