Psychotropic Medications for Children in Foster Care: We've Come a Long Way

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The use of psychotropic medications for children and adolescents has long been a controversial subject. The topic of psychotropic medications for children and adolescents in foster care generates a particularly polarizing response.

Over the past decade, a growing body of data indicates that there has been a significant increase in the rates by which psychotropic medications are being prescribed to children and adolescents. In addition, the use of more than one psycho-tropic medication concurrently has increased significantly.

There is an array of evidence demonstrating that children in foster care suffer from more emotional problems than children in the general population. Fifty to 80% of children in foster care present with significant mental health problems. Histories of abuse and neglect, general family dysfunction, parental substance abuse, and poverty, coupled with the potential trauma associated with being removed from their homes and being separated from siblings, are all believed to contribute to a greater percentage of foster children with mental health diagnoses. Considering these vulnerabilities, it is not surprising that the estimated rates of psychotropic medication use for youth in foster care are much higher (ranging from 13-52%) compared with approximate rates of 4% in the general pediatric population, 5-6% in low-income populations qualifying for Medicaid services, and 21% among youth receiving Social Security income. Therefore, there is rising concern about the both over- and under-use of psychotropic medications for youth in foster care.

In December 2011, the United States Government Accountably Office (GAO) released its report on this subject, Foster Children, HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions. The report analyzed Medicaid claims data for psychotropic medication prescriptions in five states (Florida, Massachusetts, Michigan, Oregon, and Texas) during 2008. Their results revealed that "foster children in these five states were prescribed psychotropic medications at higher rates than non-foster children who received Medicaid during 2008." The report indicated that in Florida specifically, 22% of foster children were prescribed psychotropic medications, compared to 8.2% of non-foster children.

Our Kids--a nonprofit-led, community-based care agency selected by the Florida Department of Children and Families to provide foster care, adoption, and related services for Miami-Dade and the Florida Keys--recognized the significance of these findings and set out to evaluate whether there had been any change in these trends in recent years.

Since data utilized in the GAO report was from 2008, Our Kids examined data from 2011-2012 to assess if any changes exist. During the 2011-2012 fiscal year, an average of 1,925 children were placed in foster care, and children in foster care in Miami-Dade and Monroe Counties were prescribed psychotropic medications at a rate of 12.37% during this 12-month period. This rate of psychotropic medications for children in foster care in Miami-Dade and Monroe Counties is a stark difference between the reported 22% in 2008.

Continuous analysis and improvement in the identification and delivery of mental health services is a priority for Our Kids and its child welfare case management subcontractors. Florida's Community-Based Care agencies have implemented several forms of clinical oversight for the delivery of timely and quality mental health services for children in foster care, including monitoring the use of psychotropic medications. The goal is to provide foster children with a stable placement, prompt clinical assessment to determine service needs, and continuous oversight of behavioral health services.

Training for individuals who care for children in our care is critical, and that's why Our Kids has partnered with South Florida Behavioral Health Network and our partners at the Department of Children and Families to ensure that case workers, protective investigators, and foster parents all receive appropriate training to help monitor and care for children who are receiving psychotropic medications.

The progress made in this area over the past four years has been significant. However, we face challenges when it comes to foster children and the use of psychotropic medication. You cannot determine if a child is being appropriately medicated merely by looking at statistics. To answer this, you have to look at each child individually.

While some are easily distracted by the debate over whether children should or shouldn't be prescribed psychotropic medications, the focus should be on children obtaining the most appropriate, high-quality care--psychosocial, physical, educational, and pharmacologic--for the emotional, educational, behavioral, psychological, and psychiatric challenges they may face.

The reality is that there will be instances in which children will be prescribed psychotropic medications to ensure their well-being and safety. Our Kids, its subcontracted case management agencies, and the Florida Department of Children and Families have all made this a priority, evidenced by the rate at which children in our care are prescribed these medications.

Ensuring that proper measures are in place--including close monitoring to determine medical necessity, training for child welfare professionals and caregivers on the different classes of medication and their purposes, and ongoing monitoring of the child's behavior at home and in school--is critical to seeing that children are safe and well-cared-for while they are in our community's care.

Michelle Montero-Caicedo, MS, LMHC, is the Chief of Clinical Services at Our Kids of Miami-Dade/Monroe, Inc. Daniel Castellanos, MD, is the Medical Director of South Florida Behavioral Health Network and a professor and founding chair of the Department of Psychiatry at the Herbert Wertheim College of Medicine at Florida International University.

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