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Psychopharmacology
Attempting to Provide Care for Vulnerable Children
Psychopharmacology and the Foster Care System
Posted July 19, 2015
The foster care system is a large complex system of care that has as one of its major functions the care of abused and neglected children. In the U.S., in 2011, 400,000 children resided in foster care.
Each state has its own foster care system; at a national level, the state foster care systems are funded by Medicaid, under the Department of Health and Human Services.
Children in the foster care system have a high rate of psychiatric illness; it is estimated that between 50% to 80% of the foster care population is psychiatrically disturbed. In addition to being removed from their families, many children in foster care have been physically abused, neglected, or sexually abused. It is expectable that early adverse life events such as these would be associated with psychiatric symptoms. Compared to non-foster-care children receiving Medicaid, children in foster care receive five to eight times more mental health services.
There are bitter complaints that psychiatric medications are overused in children in foster care. Compared to non-foster-care children receiving Medicaid, children in foster care receive two to eight times more prescribed psychiatric medications.
The U.S. Government Accountability Office and the Department of Health and Human Services have recommended that all states develop red flags for evidence of inappropriate psychopharmacological practices in the foster care system.
Four fifths of the states responded, and the proposed red flags can be summarized as: (1) doses too high, (2) age too young, and (3) too many medications per child (polypharmacy).
The issues are complex; many foster children who should be treated with medication may not be. In a major study of children aged two to fourteen years in foster care, only 25% of children with severe behavioral needs received any services at all (1).
The Pennsylvania Department of Human Services commissioned the Policy Lab of the Children’s Hospital of Philadelphia to study psychotropic medications received by children in foster care in Pennsylvania (2). The results of the study were announced at a June 16th, 2015, press conference at the Children’s Hospital of Philadelphia.
The study found that 42% of the children in foster care received psychotropic medications compared to 16% of children in a non foster care Medicaid population. 22% of children in the foster care group received antipsychotic medication compared with 5% in the non foster care Medicaid population.
Half of the children taking antipsychotics in the foster care population had a diagnosis of ADHD and no additional diagnoses or medications. Antipsychotics are not the preferred treatment for ADHD.
Because the rate of overall disturbance in either sample was not reported it is not possible to gauge whether the overall increased rate of medications in the foster care sample was higher than would be expected for a similarly ill group of non foster care Medicaid children.
The specialty of the prescribers was not provided. Who was prescribing these medications? Were child psychiatrists prescribing antipsychotics for ADHD or were less highly trained professionals? Knowing the professional identify of the prescribers would be helpful.
Stimulants are the on-label medication of choice for ADHD. The use of stimulants in the sample was not described. It is possible that stimulants were not used appropriately, which may have resulted in the use then of antipsychotics. More information about the use of stimulants would have improved the interpretability of the report.
It is heartening to see studies such as this and others including the excellent American Academy of Child and Adolescent Psychiatry practice parameter for youth involved in the child welfare system (1).
References
1. Lee, T et al Practice parameter for the assessment and management of youth involved with the child welfare system. JAACAP 54:502-515 June 2015
2. Matone et al Psychotropic Medication Use by Pennsylvania Children in Foster Care and Enrolled in Medicaid: An Analysis of Children Ages 3-18 Years. Philadelphia PolicyLab at The Children’s Hospital of Philadelphia.
Copyright: Stuart L. Kaplan, M.D., 2015.
Stuart L. Kaplan, M.D., is the author of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis. Available at Amazon.com.
