On Friday, November 20 the American Youth Policy Forum sponsored a Capitol Hill briefing on the topic of How Research Evidence Informs Foster Youth Medication Policies. The panel discussion included an examination of definitions, usage and oversight of psychotropic and other medications for youth and children in foster care. The discussion reached beyond the numbers into an examination of the challenges of crafting effective policies to best serve children in foster care in a way that protects and serves their health and mental health needs.
Effective policy on the use of psychotropic medication involves extensive consultation within the state, collaboration between various entities and agencies at the state level including child welfare, and effective training for key monitors and partners from judges, caseworkers, foster parents to health providers.
The panel presentations included opening comments from Loretta Goodwin, AYPF, Laurel K Leslie, American Board of Pediatrics, Thomas Mackie, Rutgers School of Public Health, Christopher Bellonci, Tuffs University School of Medicine, and Deborah Lancaster, New Jersey Department of Children and Families.
The briefing was framed around for specific questions of, Is there evidence that we should be concerned about children in foster care and the use of psychotropic medication; What evidence is available or lacking to inform state oversight of psychotropic medication use; How are states responded using local evidence to measure medication use; and What has been one state’s experience?
Research indicates that rates of emotional or behavioral disorders are more common in foster care than within the larger community ranging from 50 to 80 percent of foster children compared to one to 25 percent in the general population. Additional research indicates that 20 percent of foster care placement changes are related to behavior problems and that youth with externalizing problems are twice as likely to remain in foster care 18 months after entry.
A closer look at Medicaid enrollment as well as a comparison between children in the TANF, SSI and foster care populations showed that within TANF 26 percent of children were taking two or more psychotropic medications (one percent 4 or more), within the SSI/Disability population 46 percent of children were receiving 2 or more medications (four percent 4 or more) and within the foster care population 40 percent were receiving 2 or more medications (four percent 4 or more).
In regard to state actions being taken the briefing highlighted recent research at the federal level including studies by the GAO but greater detail was offered through the Tufts Research Team. That data included research from 2009-10 and more recently 2011-14. In the 2009-10 research they looked at state variations in terms of psychotropic medication review. Research indicated the 53% of states were using both perspective reviews of psychotropic medication use and as well as concurrent review of psychotropic medication in some form. Research indicates that 20 percent of monitoring mechanisms did not routinely have a licensed health professional providing review of safety concerns for psychotropic medication use.
States have a variety of approaches in regard to policy. In one area, informed consent for children in foster care, the adult designated may include biological parents, caseworkers, child welfare administrators, child welfare units with mental health expertise, the judicial system and/or the youth him/herself. There were challenges in many of these approaches, such as lack of expertise by judges, parents being an official designee but in reality defaulting to other adults to foster parents having conflicting feelings about such a role.
In regard to the third question how are state using local evidence collaboratively, the panel focused on six states: Illinois, New Jersey, New York, Oregon, Rhode Island and Vermont. Key issues to address included policies around informed consent procedures, how to generate real-time medication utilization data, how to develop red flags on use based on age, dosage, diagnosis, class of medicine and addressing co-pharmacy and polypharmacy use, and how to develop oversight and monitoring that address their unique jurisdiction and practice concerns.
The briefing concluded with a closer look at one state, New Jersey. The state has set up medication policy based on the American Academy of Child and Adolescent Psychiatry (AACAP) the American Academy of Pediatrics (AAP) and the Child Welfare League of America (CWLA) guidelines. The state also included a review of other states, used an internal work group, and drafted a policy that was consistent with their department values. Key components of New Jersey policy included: psychiatric evaluation, authorized prescribers, treatment plans, informed consent, medication guidelines, safety moderate monitoring guidelines, and prescribing parameters.
All children in foster care are enrolled in the state Medicaid program with the state having a system of care. New Jersey has 47 child health units. These units include a nurse who can provide oversight with every child having a nurse who can provide oversight in terms of their medication and practice health practices. The child health units are tasked with developing a health care plan specific of the child’s health needs, and coordinates healthcare services including access to healthcare in a timely follow-up manner. In cases where there are additional questions or concerns the policy allows for the state to have consultations with the Department of Children and Families-Child Adolescent Psychiatrists
In both the New Jersey model as well as other information presented, it was clear that proper oversight required just monitoring or tracking numbers. It requires an extensive amount of consultation, collaboration across agencies and various partners, and training for key players including judges, caseworkers, foster parents and parents and that such actions will have to crafted according to state and local characteristics.