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California's Plan to Curb America's Overmedication of Foster Kids

The state may adopt what could be a national model for states to curb the prescription of antipsychotics to children in foster care.

Stefan Boekels/Corbis
In the United States, low-income and foster-care kids are prescribed psychotropic drugs at an alarmingly higher rate than their peers in America or abroad. Governing recently wrote about the problem and what states are doing to deal with it in March. But since then, California began closing in on a package of bills that could make the state a leader in controlling overmedication.

Earlier this month, the California state Senate unanimously passed four bills that would strengthen the state’s monitoring system for foster kids' prescriptions, require stronger evidence documenting the need for medications, add more medical expertise in the area of oversight and force group homes that overprescribe to develop plans to change their practices. Some of those ideas aren't new, but experts say adopting all of them together could make California a model.

"We feel pretty confident that this package of four bills is really more comprehensive and targets so many different aspects of the problem that other states really have not been targeting,” said Bill Grimm of the National Center for Youth Law, the group behind the legislation.

Psychotropic drugs range from amphetamines, which are often prescribed for ADHD, to antidepressants and antipsychotics. Antipsychotics were originally intended for the treatment of severe mental health illnesses but have increasingly been prescribed to children with behavior issues since the 1990s. Numerous studies show low-income children, particularly those in foster care, are prescribed psychotropic drugs at rates far above privately insured kids. The Office of Inspector General has raised alarms in numerous reports. Since 2011, federal authorities have required states to report annually about steps they’re taking to curb psychotropic prescriptions. 

California is one of only a few states that requires a judge to approve prescriptions for psychotropic drugs, but according to an investigative newspaper series, it still prescribed them to about a quarter of foster kids (compared to just 4.8 percent of privately insured children), over the past decade. The bills would revamp the court system of prior approval. The form that doctors submit to judges, for instance, would have to show that doctors tried other therapeutic services first. Judges would also have the power to request a second opinion or return the form for more information, and doctors would have to get the written consent of children 14 and older. The bill also offers training to everyone from judges to group-home employees on the appropriate uses of these drugs and expands data-sharing between the Medicaid system that pays for care and the child welfare system.   

The two most notable changes, though, are increased monitoring of group homes and expanded use of nurses -- both of which are uncommon. The newspaper series highlighted links between group homes for foster kids and high rates of prescription medications, which children often had to take as a condition of staying there. With better data-sharing, state officials would flag group homes with the highest rates of psychotropic prescribing and require them to make plans to reduce overmedication. Nurses, meanwhile, would monitor the side effects of antipsychotics such as serious weight gain, diabetes and neurological disorders.

The bills haven’t encountered opposition, but they still need to pass the California Assembly and get the signature of Gov. Jerry Brown who's been fairly quiet on the issue even though it generated a lot of interest after the newspaper investigation. The bills come at an estimated cost of $5 million in the first year, with about $4 million thereafter. To Anna Johnson, a policy analyst with the National Center for Youth Law, Brown's reputation as a budget hawk means he's less likely to support the bill package. 

“His main legacy here has been that he’s had this balanced budget, but for foster kids [for] whom every day feels like a rainy day, we feel like he could do more to protect them,” she said.

When asked for his opinion on the package of bills, his press office said Brown doesn’t typically comment on pending legislation.

Gov. Jerry Brown giving a presentation. (AP/Rich Pedroncelli)

Shadi Houshyar, vice president of child welfare policy at the advocacy group First Focus, agrees that the bills would be a positive step, but she also thinks states are generally behind on an element that’s critical to actually replace drugs: access to services like intensive counseling and individualized case management.

“The biggest challenge is how you increase the use of evidence-based therapies for kids in addition to the monitoring strategies,” she said. 

The way to do that, according to Houshyar, is to offer those services through Medicaid, which allows states to leverage federal funding, and make them accessible through child welfare departments. Some notable examples of places that do that are Arizona -- which has a Medicaid plan specifically for foster children -- Michigan and New Jersey.

For California, the money is there, said Grimm. Since 2004, the state has raised $13 billion for mental health services from a ballot measure that raised taxes on people earning more than $1 million a year. But an independent state oversight agency found recently that much of the spending is unaccountable and poorly prioritized, with little sense of exactly how the money is being spent and what it’s producing. Grimm’s group wants to ensure that money is going to children in the foster-care system.

 “There is a considerable amount of money and resources out there,” he said. “The question is to what extent is that money being used for children?”

Chris covers health care for GOVERNING. An Ohio native with an interest in education, he set out for New Orleans with Teach For America after finishing a degree at Ohio University’s E.W. Scripps School of Journalism. He later covered government and politics at the Savannah Morning News and its South Carolina paper. He most recently covered North Carolina’s 2013 legislative session for the Associated Press.
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