Watchdog Finds that 1 in 3 Foster Kids Lack Med Management

Thousands of children in foster care who are taking psychotropic medications are not receiving adequate treatment safeguards, according to a report released by a federal watchdog in September.

The report, conducted by the Office of the Inspector General of the Department of Health and Human Services (HHS), found that in five states studied, 34 percent of foster children who were currently prescribed one or more psychotropic medications were not receiving treatment planning or medication monitoring—both of which are required by each of the five states and recommended by professional groups. Though the results cannot necessarily be extrapolated to other states, the authors said, the five states chosen had the highest percentages of foster children taking psychotropic drugs.

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Twenty percent of those children across Iowa, Maine, New Hampshire, North Dakota, and Virginia did not receive treatment planning, which is typically a document—created by the foster child’s medical team and verified with the prescribing doctor—that outlines what psychotropic medications are being prescribed and the medical rationale for each treatment. Treatment plans are typically seen by caseworkers, foster parents, and prescribers, and are intended to maintain continuity of care for the child if they change families or start seeing a new doctor, as well as reduce the risk of harmful medication interactions.

Twenty-three percent of children did not have their medication adequately monitored in follow-up appointments to check for side effects and track progress or setbacks. Eight percent of the children received neither treatment planning nor medication monitoring—putting them at greater risk for inappropriate treatment or dangerous medication combinations, according to the report’s authors.

“These kids are already at risk,” says Assistant Inspector General Ann Maxwell, who oversaw the evaluation. “They were separated from their families, and they are coping with mental health challenges.” Approximately 80 percent of foster children enter foster care with significant mental health needs, she says. As of 2012, almost 30 percent of U.S. children in foster care were estimated to be taking at least one psychotropic medication. (A CDC report found that overall, about 6 percent of U.S. children between the ages of 12 and 19 reported recent psychotropic drug use.)

“Drugs can tip the scale one way or the other,” Maxwell says. “Appropriate treatment can tip the scale by allowing them to cope and function—but on the other hand, inappropriate treatment can tip the scale in the other direction, causing negative outcomes.”

She cites one case included in the report, in which an 11-year-old boy in foster care was prescribed several psychotropic medications for reactive attachment disorder, conduct disorder, anxiety, and ADHD, but wasn’t adequately monitored in the subsequent months. His foster parents were unable to get the prescriptions refilled, and when the child finally saw a psychiatrist three months later, the doctor noted that “the child had ‘lost the ability to maintain normal psychological function,’” Maxwell says. His subsequent behavioral challenges had resulted in him being suspended from school. “You can see the impact of not getting that medication was pretty immediate on that child’s life,” she notes.

In another instance, a 6-year-old child was put on four different psychotropic medications with no treatment plan in place. When his treatment regimen was finally reviewed by a state-employed nurse coordinator several months later, it was found that one of his prescriptions wasn’t medically necessary, and another was exacerbating symptoms of one of his conditions. He was taken off both medications.

“A good proportion of kids in foster care who take medication are getting two, or three, or more,” says Erin Barnett, an assistant professor of psychiatry at the Dartmouth Geisel School of Medicine who studies how psychotropic medications are prescribed to foster children but wasn’t involved in the OIG’s report. “There are very few studies that have looked at the effects and side effects of prescribing two or more psychiatric medications in kids. But we’re doing it all the time—and with every new med, we’re adding more risk.”

Though the foster child’s medical team is responsible for designing treatment plans and initiating appropriate monitoring, lack of education and support for foster families could be compounding this issue, too, Barnett says. “Parents—and youths themselves—don’t know what the meds are for, and don’t know what kind of monitoring is supposed to be done,” she says, based on the results of several studies she’s conducted. “I’m not blaming the clinical prescribers, necessarily—but there are huge barriers to knowledge” that need to be addressed by clinicians, which can be challenging to do during short primary care visits, she adds.

A lack of funding for foster care—specifically for behavioral services that could reduce the need for medication—could also be a significant factor here, she says, particularly in cases where too many meds are prescribed. “Foster care has been called the ‘gateway to overmedication.’ You can’t help but wonder: If we had more infrastructure, would we be able to provide more oversight?”

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Scott Kessler, a former foster (now adoptive) parent who lives in Massachusetts, says an apparent lack of medication monitoring has greatly impacted his son’s care and overall well-being. “It just permeates the whole foster system,” he says. When his son, now 15, first came to live with them as a foster youth six years ago, Kessler says he was taking two different antipsychotics, a sleeping medication, and several others. “It was a drug cocktail,” he says. “He was kind of comatose when we first got him. It helped control his behavior some, but he was dull—there was no shine to him.”

He doesn’t see an easy solution, however. “I think the reality of the situation is that behavioral interventions take a lot of consistent effort,” he adds. “I can understand, as a caregiver, why [medications] would make life a lot easier.”

Part of the problem is that care for foster children is fragmented, Maxwell says. “Unlike children in intact families who have a single interested party, the care for children in foster care is delivered by their caseworker, a foster family, and their medical and mental health clinicians. All of those can change.” But while that can make adequate monitoring more challenging, she adds, it also makes it “even more critical to protect these children.”

The OIG’s report recommended that HHS’ Administration for Children and Families (ACF) develop strategies to help close the compliance gap for existing guidelines, Maxwell says, as well as “raise the bar” and develop even stronger oversight measures for children in foster care who are taking psychotropic medications. ACF responded to the initial recommendations by saying they concurred with some of them but not with others, and that they would search for other ways they could provide training or technical assistance to states. They have not, as of yet, clarified what specific steps they will be taking to do so, Maxwell says.

“We have a protocol which gives the department a chance to comment on the report,” she says. “Then, we’ll follow up at the six-month mark to get the final action plan. Then we will continue to follow up with the department until we consider those recommendations closed.”

Regardless of the specific steps ACF takes, the report’s findings indicate that “the current approach is insufficient, and more needs to be done,” Maxwell says. “That 34 percent represents approximately 4,500 children across the five states we reviewed. The way I look at it, that’s 4,500 children at greater risk than they need to be.”