WASHINGTON — Thousands of children in foster care may be getting powerful psychiatric drugs prescribed to them without basic safeguards, according to a federal watchdog’s investigation that finds a failure to care for youngsters whose lives have already been disrupted.
The report from the Health and Human Services inspector general’s office found that about 1 in 3 foster kids from a sample of states were prescribed psychiatric drugs without treatment plans or follow-up, which are considered standard for sound medical care.
Kids getting mood-altering drugs they don’t need is only part of the problem. Investigators also said children who need medication to help them function at school or get along in social settings may be going untreated.
The drugs involved include medications for attention deficit disorder, anxiety, PTSD, depression, bipolar disorder and schizophrenia. Foster kids are much more likely to get psychiatric drugs than children overall. A copy of the report was provided to The Associated Press.
“We are worried about the gap in compliance because it has an immediate, real-world impact on children’s lives,” said Ann Maxwell, an assistant inspector general.
Among the situations investigators encountered was the case of a 6-year-old boy diagnosed with ADHD, learning and speech disorders, outbursts of temper and defiance, and hair-pulling disorder. He had been put on four psychiatric drugs.
But a medication review questioned the need for some of those drugs. Of the four, two were discontinued and one was reduced in dosage, investigators said. Two different medications were prescribed.
Investigators found no evidence that a treatment plan for the boy had been developed in the first place, before starting him on medication.
In another case, an 11-year-old boy had been put on two medications after being diagnosed with ADHD, anxiety and behavior problems. But over a three-month period his foster mother had problems getting prescription refills. By the fourth month, the boy’s life had gone out of control. His decline included stealing, lying, bullying and an in-school suspension. The lack of effective follow-up contributed to the downward spiral.
Investigators found there was no requirement in that state for case workers to follow up with foster parents about medications.
“These children are at greater risk of not getting the medications they need, but equally important, they are at risk of getting powerful medications that they do not need,” Maxwell said.
The inspector general is recommending that the HHS Administration for Children and Families develop a strategy to help states meet their existing requirements for prescribing psychiatric drugs to foster children, and to generally raise standards for case-by-case oversight.
In a formal response to the inspector general, the children’s agency said it may need additional legal authority. In a statement to The Associated Press on Sunday, the agency said it is committed to making sure foster children get psychiatric medications only when medically appropriate. The agency added that it is reviewing the report and noted that the inspector general’s findings covered just five states.
Foster children come into the mental health system with added complications. Their most basic connections in life have been stressed or severed. They may have suffered neglect or abandonment. They may have witnessed or been a victim of abusive behavior or violence.
A 2010 study from the Tufts Clinical and Translational Science Institute found that estimated rates of psychiatric drug use among youth in foster care are much higher (13 percent to 52 percent) than among youth overall (4 percent).
Compounding the challenge for foster children is the fact that responsibility for their well-being is often divided among foster parents, birth parents, relatives and case workers. That can increase chances for miscommunication and conflict, not to mention everyday problems going unaddressed until they escalate.
Caring for foster kids is a shared responsibility of state, local and federal agencies. The federal government provides grants to state programs and also covers health care for foster children through Medicaid, which spends hundreds of millions of dollars annually on psychiatric drugs. Nationally, it’s been estimated that about 120,000 children in foster care take at least one such medication.
The inspector general scrutinized a sample of 125 cases from each of five states with the highest overall percentages of foster children treated with psychiatric drugs. Those states were Iowa, Maine, New Hampshire, North Dakota and Virginia. The cases covered the period from October 2014, through March 2015. Investigators looked at each state’s compliance with its own particular requirements for treatment planning and follow-up.
Maine had the fifth highest rate nationally of children in foster care being treated with psychiatric medications, the inspector general found. Some 32.7 percent of Maine children in foster care at any point in federal fiscal year 2013, which covered Oct. 1, 2012, through Sept. 30, 2013, were treated with psychiatric drugs. That worked out to 1,155 children.
North Dakota had the highest rate: 36.7 percent.
While Maine guidelines require treatment plans for all children in foster care, the inspector general found that about 28 percent of the children whose cases they reviewed lacked such a plan. Children in foster care who had medication plans didn’t necessarily have up-to-date plans: About a quarter didn’t see those plans reviewed quarterly by doctors as state guidelines require.
Eleven percent of children in foster care being treated with psychiatric medicines didn’t receive medication monitoring to ensure they were receiving the right mix of medications.
And while child welfare caseworkers in Maine are required to participate quarterly in medical or psychiatric appointments for children prescribed psychiatric drugs, the inspector general auditors found this often wasn’t happening.
Maxwell said the finding that 34 percent of children did not have either treatment plans or follow-up monitoring translates to about 4,500 children in the five states examined. She said the national number would certainly be higher but the design of the inspector general’s review did not allow for a simple extrapolation. Even among the five states cited there were wide differences.
The focus on foster children is part of a growing awareness in society about proper care in using psychiatric medicines with vulnerable people, which also includes elderly nursing home residents.
As children involved in the child welfare system because of alleged abuse or neglect by parents, “these kids are set up for mental health problems” said Dr. Lindsey Tweed, a child psychiatrist and president of the Maine Council of Child and Adolescent Psychiatry.
The inspector general was right to focus on the quality of mental health care children in foster care receive and not simply the percentage treated with psychotropic medications, Tweed said.
“It would be great to get more focus and more resources on treatment planning and treatment monitoring,” he said.
Maine Focus writer Matthew Stone contributed to this report.
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