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Are We Overmedicating Foster Care Children?

A new GAO report finds that states don't do a particularly effective job of monitoring kids on psychotropic meds.

Mental health issues are front and center in human services. Every day, caseworkers work in an environment where mental health services aren't as robust as they should be and where medication for kids in custody sometimes serves as a substitute for more appropriate care.

I know of one state where a few years ago a crew of data hounds found that on Fridays, requests for psychotropic meds for kids in custody -- especially those in institutional settings -- spiked. Why? The unavoidable conclusion the data crunchers came to was that weekends at institutional facilities means fewer staff, and fewer staff means that properly attending to kids' needs is tougher. To be blunt about it, it's just cheaper and easier to drug kids than to take care of them in the most therapeutically appropriate way.

Of course, concerns over the use of medication among foster children certainly aren't exclusive to examples like that one. A Government Accountability Office (GAO) report released at the end of last year highlights two alarming facts: First, children under state supervision generally aren't getting consistent, appropriate mental health care of any kind, even though mental health issues are a huge part of why kids wind up in state custody. Second, nearly 20 percent of children in foster care are taking psychotropic medication -- three times the rate of children on Medicaid and four times higher than kids covered by private health insurance.

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Psychotropic meds, which are used to manage mood and behavioral disorders, can be effective, but the GAO report notes that using them wisely and well takes skill and close monitoring. And according to the GAO, kids who are prescribed medication don't usually receive timely follow-up visits. Furthermore, "mental health researchers and others have stated that there is a need for further research on the safety and effectiveness of anti-psychotics for children," the report's authors wrote, "particularly long-term effects."

Dorothy Miller and Kathleen Noonan, researchers with PolicyLab, the policy research arm of the Children's Hospital of Philadelphia, have been following the issue of psychotropic meds and children for several years. They are quick to emphasize that PolicyLab isn't against the use of medication for children. "If they work, and suddenly a kid is able to stay in school and do well, that's great," says Noonan. Adds Miller, "It's important and helpful to kids who need them, but they have to be monitored. and they should be accompanied by other therapeutic interventions."

Miller and Noonan agree with the GAO report's findings: The extent to which states do a good job of monitoring and tracking is very uneven. It is especially uneven in states where human services are administered by counties with state oversight, they note. But there are states that have become models for how to deal with the issue. Miller and Noonan point to Texas as such a state. "They made a bold, strong move in favor of kids," says Noonan.

Legislation signed by Gov. Rick Perry that went into effect last month expands oversight of psychotropic medication in two ways. First, the law requires that kids who've been prescribed medication be seen by their prescribing physician at least every 90 days. Second, the legislation requires that judges overseeing a child's foster care case be informed of behavioral and pharmacological treatments at all court hearings.

While it is clearly important to focus on the complicated mix of drugs and kids, perhaps it is more important to focus on the issue of mental health overall. The GAO report notes that "30 percent of foster children with a potential mental health need had not received any mental health services within the previous 12 months or since the start of the child's living arrangement, if less than 12 months."

There are lots of reasons for this, not the least of which is a lack of skilled mental health care professionals willing to deal with a population that's typically covered only by Medicaid. But some states are tackling that larger issue. Massachusetts' Child Psychiatry Access Program and Washington's Partnership Access Line are cited by the GAO as programs that have improved access to mental health care for kids in custody.

Still, we are way behind in providing the sort of appropriate, high-quality mental health services that will be necessary in the long run if we're going to really help kids escape multigenerational cycles of state involvement.


UPDATED: This story has been updated to remove a reference to a specific state, out of concern for the children in public custody there.

Elizabeth Daigneau is GOVERNING's managing editor.
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