Stricter Monitoring of Psychotropic Meds in Foster Kids Needed

Prescribing Rates Described as 'Alarming'

Deborah Brauser

December 02, 2011

December 2, 2011 — The federal government needs to step up and do more to oversee and monitor the use of psychotropic medications in children who are in foster care, according to the US Government Accountability Office (GAO).

In a report published online December 1, the GAO notes that although foster children often have increased mental health needs because of their greater exposure to traumatic experiences than do other children, the rates of concurrent treatment medication use are alarming.

When investigators examined data on children in 5 states, they found that not only did those in foster care have 2.7 to 4.5 times higher rates of psychotropic drug use in 2008 than nonfoster children enrolled in Medicaid programs, they also had higher numbers of prescriptions.

"[N]o evidence supports the concomitant use of five or more psychotropic drugs in adults or children, yet hundreds of both foster and nonfoster children...had such a drug regimen," they write. They noted that even more children were prescribed doses that were higher than maximum levels indicated in guidelines, which can often lead to an increased risk for serious treatment-related adverse events.

The investigators also found that these medications were prescribed to from 0.3% to 2.1% of foster children who were younger than 1 year.

"According to our experts, these cases raise significant concerns because infants are at a stage in their development where they are potentially more vulnerable to the effect of psychotropic drugs," write the authors of the report.

State Oversight Lacking

When monitoring the states' oversight procedures of psychotropic prescriptions in foster care children through October 2011, the investigators found that none met all the recommended guidelines from the American Academy of Child and Adolescent Psychiatry. The states evaluated were Florida, Massachusetts, Michigan, Oregon, and Texas.

The guidelines include recommendations for identifying which caregivers are allowed to give consent, and that a consultation with a child psychiatrist should be provided on request.

The Department of Health and Human Services (HHS), which oversees Medicaid, currently provides limited guidance and no formal endorsement of specific oversight measures to states dealing with these issues.

However, the HHS has now agreed with the GAO's recommendations to consider "endorsing guidance to state Medicaid and child welfare agencies on best practices."

"Agency comments will be incorporated and addressed in a written report that will be issued in December 2011," report the investigators.

A recent study published in Pediatrics and reported by Medscape Medical News showed that children in the foster care system were more likely to receive 2 or more overlapping antipsychotic medications than those who qualified for Medicaid on the basis of a disability or low income. They were also more likely to receive these medications for a longer duration.

In the GAO report, the investigators note that Massachusetts had the highest psychotropic prescription rates in children aged 17 years or older, at 39.1%. In contrast, Oregon had the lowest rate of the states that were studied (19.7%).

The Child and Family Services Improvement and Innovation Act was recently enacted to establish protocols for monitoring psychotropic medication for foster children.

"Under the act, each state is authorized to develop its own monitoring protocols, but HHS-endorsed, nationwide guidelines for consent, oversight, consultation, and information sharing could help states close the oversight gaps we identified and increase protections for this vulnerable population," the authors write.

Displacement Trauma Disorder?

Commenting on the report, Kalyani Gopal, PhD, a clinical psychologist from Merrillville, Indiana, and a member of the Lake County Child Protection Team, said the report's findings did not surprise her.

"I'd say at least 70% to 75% of the foster children I've seen over 25 years of practice are medicated," Dr. Gopal told Medscape Medical News.

Dr. Gopal, who is also a contracted provider for the Department of Child Services in Indiana, said that these children also take concurrent medications.

"Oftentimes they have at least 1 medication plus another to fight the first one's side effects. I've seen many kids on 8 to 9 different meds at the same time. And what's most startling is that most of these meds are not meant for children who are only 4, 5, or 6 years old."

Dr. Gopal said she does not believe that all of these children actually have a mental health illness. Instead, she argues that many have a displacement trauma disorder.

"This is a trauma that occurs because a child is removed from everything that he or she is familiar with. Even if a kid comes from a home that has substance abuse or physical abuse, that child is very familiar with that environment," explained Dr. Gopal.

"Because of this displacement, children do not know how to behave when they're placed in a new home that introduces a whole different culture. So it takes awhile for them to settle down, and many are lying, they're hyperactive, they're being disruptive. Foster parents who are not equipped or not trained don't know how to react to this."

Dr. Gopal said foster parents then go to physicians for solutions to these acting-out behaviors, and often ask specifically for help through medications.

"Instead, I think trauma therapy should be used. Aggressive parent-child psychotherapy can be employed to address the trauma, and it's remarkable how well this form of therapy works. Hypnotherapy and especially trauma-focused cognitive behavior therapy have also worked tremendously well in these children, as has eye movement desensitization reprocessing."

"These children should not be on multiple medications, especially when there's other treatment that is very effective and available and doesn't cost a lot of money," she concluded.

Dr. Gopal has disclosed no relevant financial relationships.

The full report was published online December 1 on the GAO's Web site.

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