PolicyLab

Last Thursday, May 22nd, the federal Government Accountability Office (GAO) released a report on how to improve oversight of mental health drugs, also called psychotropic medications, for children in foster care. Psychotropic medications are prescribed at much higher rates for children in foster care than they are for children generally.  

Across the board, experts, researchers, and politicians agree that the rates of psychotropic medications for children are inappropriately high and should be lowered.  In fact, this issue has elicited three GAO reports to date, and today at 2pm, the Subcommittee on Human Resources of the Committee on Ways and Means will hold a hearing on the use of psychotropic medications among children in foster care.  Yet, despite widespread agreement on the significance of the problem, the solution to high rates of psychotropic medications has been very difficult to identify. 

As PolicyLab’s research shows, since the mid-2000s, states and the federal government have become increasingly responsive to psychotropic prescribing.  However, in spite of the enactment of many initiatives aimed to curb prescribing to children in foster care, most states have only been able to slow the increase in prescribing, with very few states reporting overall decreases in rates of psychotropic medications.   For many advocates, providers, parents, and social service agency workers, this is frustrating: If we know this is a serious problem and there is political will to address it, why is it so hard to find a timely solution?

Three Major Reasons

We identify three major reasons why solving the issue of psychotropic medications for children in foster care has been so so difficult.  First, psychotropic medication may be the only option available to some children.  When a child in foster care is experiencing difficulty with adjustment or displaying behavior that is inappropriate, caregivers can feel overwhelmed.  Medications can serve as an effective and expedient answer. And in many instances, healthcare providers, social services systems, and caregivers may be unaware that there are proven alternatives and, given the nascence of our understanding of child trauma, may be unaware of unique treatment needs of children in foster care.

Research shows that certain types of behavioral therapy can have a significant and positive impact on children are able to address root causes of behavioral disturbances (e.g., trauma), and do not carry the risk of negative side effects of psychotropic medications.  Even though the research is clear on the benefits of behavioral therapy, there are barriers to receipt of this treatment that are not present for receipt of medication treatment. Namely, providing therapy requires that insurance companies pay for it, that the location and timing are convenient for families and foster caregivers to access, and that the therapy providers are well-trained.  These requirements translate to a much greater upfront investment of both time and money by all stakeholders involved in order to successfully make a behavioral therapy alternative available.   And in many instances, stakeholders are unable or unwilling to provide the upfront investment. 

Second, the systems that need to change are complex and the responsibility for a child’s health care is diffuse.  Typically, a child’s biological parent or parents are responsible for the medical care of their children up to a certain age.  When a child is in foster care, the situation can become much more complicated as child welfare agencies, foster families, and biological families share responsibilities and rights in ensuring the health of the child.  As a result, the person who can legally consent for a child’s medical care can be hard to identify or be impractical given the child’s circumstances.

Further, although the state’s public child welfare agency likely placed the child in foster care, a separate organization may actually be providing foster care services.  All of this makes responsibility for a child’s medical care diffuse, meaning that the child’s care and progress are complicated to track and accurately assess. The convenience of medication may outweigh the challenges of coordinating and maintaining a behavioral therapy program with such a big team.

Third, states must be the drivers of actual change for children in foster care.  While the federal government requires that states report their progress in improving oversight of psychotropic medications for children in foster care, currently, there is no financial cost to states for failing to progress significantly on this issue.  The federal government also requires state child welfare agencies to work collaboratively with the network of other state agencies playing a role in this issue, including Medicaid, physical and behavioral health care systems, and insurance companies (most likely, MCOs). 

Yet, the recently issued GAO report called states to task on improved oversight of certain insurance companies.  Beyond state agencies, state legislatures also need to drive change in policy or legislation.  This would mean ensuring that legislative or regulatory protections related to psychotropic medications are broadly communicated to stakeholders, comprehensive in scope and provide some recourse for non-compliance.

What Can We Do?

There is no easy answer to this issue.  But there are some immediate places to start.  States should make sure that their five-year child welfare agency plans due to the federal government on June 30^th include at least the following:

• Multisystem engagement of insurance and health care providers to facilitate the availability of therapeutic behavioral health care for children in all parts of a state
• Clearly designated responsibility for psychotropic medications for each child in foster care
• Publicly available information on behavioral health treatment, including psychotropic medications, developed at a reading level accessible to the general public
• Prioritization by all relevant state agencies, as well as the legislature and the governor, to collaboratively solve the issue of high rates of psychotropic medications within a state

In addition, Congress should adopt President Obama’s budget proposal to deeply invest in solving the challenge of psychotropic medications by investing in non-pharmacological alternatives to medications that can supplement or even supplant medications.

These are places to start.  They will not solve this problem, but they are steps in the right direction to address what has been a stagnating policy and practice issue at the expense of the some of our country’s most vulnerable children and youth. 

For more information on the budget proposal and the agency’s budget justification, please click here.