CONTEXT. Studies have revealed that youth in foster care covered by Medicaid insurance receive psychotropic medication at a rate >3 times that of Medicaid-insured youth who qualify by low family income. Systematic data on patterns of medication treatment, particularly concomitant drugs, for youth in foster care are limited.
OBJECTIVE. The purpose of this work was to describe and quantify patterns of psychotropic monotherapy and concomitant therapy prescribed to a randomly selected, 1-month sample of youth in foster care who had been receiving psychotropic medication.
METHODS. Medicaid data were accessed for a July 2004 random sample of 472 medicated youth in foster care aged 0 through 19 years from a southwestern US state. Psychotropic medication treatment data were identified by concomitant pattern, frequency, medication class, subclass, and drug entity and were analyzed in relation to age group; gender; race or ethnicity; International Classification of Diseases, Ninth Revision, psychiatric diagnosis; and physician specialty.
RESULTS. Of the foster children who had been dispensed psychotropic medication, 41.3% received ≥3 different classes of these drugs during July 2004, and 15.9% received ≥4 different classes. The most frequently used medications were antidepressants (56.8%), attention-deficit/hyperactivity disorder drugs (55.9%), and antipsychotic agents (53.2%). The use of specific psychotropic medication classes varied little by diagnostic grouping. Psychiatrists prescribed 93% of the psychotropic medication dispensed to youth in foster care. The use of ≥2 drugs within the same psychotropic medication class was noted in 22.2% of those who were given prescribed drugs concomitantly.
CONCLUSIONS. Concomitant psychotropic medication treatment is frequent for youth in foster care and lacks substantive evidence as to its effectiveness and safety.
Comments
Beyond Psychopharmacology
The article entitled “Psychotropic Medication Patterns Among Youth in Foster Care” (Pediatrics 2007;121:e157-e163) (1) addresses a very important topic in the care of children and youth in foster care. The article focuses on the high rate of concomitant psychotropic use among children and youth in foster care in Texas who had been prescribed psychotropic drugs, and found that, even though over 90% had these medicines prescribed by a psychiatrist, the medication chosen seldom “matched” the diagnosis. The article also summarized data indicating that disparities in treatment exist, since Caucasian and Hispanic children were more likely to have psychotropic medication use than African-American children. What is missing from this article is the context in which mental health care occurs for this population.
Children and youth enter foster care with a high incidence of genetic or familial factors and a high burden of adverse childhood experiences that predispose toward poor mental and emotional health outcomes (2). Studies analyzing data from the National Survey of Child and Adolescent Well-being (3,4,5)have indicated that 70% of children enter foster care with a history of child abuse and/or neglect, over 40% are exposed to active domestic violence at the time of child protective investigation, and over 80% have a caregiver with significantly impaired parenting skills. The same studies determined that the parents of these children have high rates of mental illness, substance abuse and cognitive impairment, all of which are likely to contribute to their impaired parenting ability. These issues, in turn, raise the risk of emotional health problems in their children, yielding rates of up to 80% at the time of placement in foster care in some studies (2).
Removal from their family is emotionally traumatic for almost all children. Foster care itself is characterized by transitions and uncertainty. Children are placed with caregivers who are often strangers to them, may experience multiple placements, and are faced with the unknown of if or when they will return home. Birth parents may or may not receive or take advantage of all the services they need to safely resume the care of their children, or may not have a significant response to treatment for mental health, drug addiction or other problems. Placement with strangers, even very nice ones, is challenging for children and teens. Ideally, visitation is an opportunity for parents and children to maintain and improve their relationship with each other. However, visitation may be unpredictable, chaotic or even harmful as children attempt to manage their participation in two or more households. For most children and youth in care, improving the health and functioning of their biological parent would have a positive impact on their well-being. In addition, recent research has demonstrated that assisting foster parents in managing children’s mental health needs in their home improves outcomes for children in foster care (6,7).
The current article, which summarizes an analysis of the Medicaid claims data from one state during one month of one year, has some shortcomings. The rates of developmental delays (7.6%) and child abuse (5.1%) reported are so low compared with national statistics that it calls into question the accuracy of other diagnostic information. This is important because the authors note a large discrepancy between mental health diagnosis and the psychopharmacological agents prescribed. This discrepancy could result from mis-reporting of the treating diagnosis and/or under-reporting of all the co-morbidities. This is further compounded in younger children by the difficulty of making an accurate mental health diagnosis since some symptoms may be the “common pathway” for different diagnoses. For example, hyperactivity and inattention might be ADHD, but could also represent oppositional defiant disorder, anxiety, depression, or a learning disability, among other things. Sometimes, in foster care, the diagnosis or diagnoses evolve as the provider becomes familiar with the child over time. Other times, a child may respond to an initial therapy and then have a series of crises that overwhelm their ability to cope. For example, parents may visit erratically or suddenly stop visiting, an expected reunification may fail to materialize, a parent may enter drug rehabilitation or be incarcerated, or a foster parent may become ill or choose to no longer care for the child. The diagnosis may evolve but not necessarily be noted as the provider changes treatment in response to the patient’s needs.
Psychotropic medication is but one modality of mental health treatment, and the study failed to mention whether these children and youth were also involved with other modalities. The study also is a point prevalence study and does not indicate whether the children and youth had been offered alternative medications that were found to be ineffective or problematic before being placed on the medications in question. The study also does not assess whether the medications were effective or not, or whether their use was monitored appropriately or not. Psychotropic medications that are used judiciously and monitored closely, in the context of other modalities and a stable foster home, can have a very positive impact on a child’s mental and emotional well-being.
Psychopharmacological medications are, in fact, sometimes used in foster care for children and teens who are “out of control” and perceived to be in “crisis”, especially if other interventions are not urgently available. This is most likely to occur at entry to foster care or at other crisis points. We know that sometimes youth in care ARE inappropriately medicated, and we MUST avoid this. It happens when the system fails. It happens when children are in a position where nobody knows them or what is underlying their behavioral struggles—when they don’t have anyone with a close enough relationship to ask the right questions or hold them accountable or comfort them. It happens when they don’t have the support they need to cope with events in their lives. Too often, it is not the child who is disordered but it is the child’s life. When we (the child welfare system and other professionals) don’t recognize the places where we can intervene in the disordered life, we are stuck with intervening only with the child. There is no medication that can take away abuse or neglect. There is no medication that can serve as a family. These are the facts of life for children and youth in foster care and it is our job to help them to cope with their realities—and to improve those realities whenever possible.
One very important question is whether children and teens may be weaned off medications over time as more appropriate “contextual” approaches are put into place. While some children and teens will undoubtedly benefit from medications used to treat psychiatric illness over the long term, others may benefit from interval treatment when they are in crisis as long as other supports and interventions are also in place and medications are used judiciously. At least two longitudinal studies have demonstrated the positive impact of foster care. Fanshel and Shinn showed in their 5 year longitudinal study that very high rates of special education placement and academic under-achievement dropped significantly over time in foster care (8). Another study by Horwitz and Simms showed that rates of developmental delay dropped and overall “well- being” improved for young children over 1 year in foster care(9).
In practice, there is a significant disconnect between what Medicaid pays for regarding children in foster care and what the evidence suggests is effective. For example, parent-child interactive therapy, trauma- focused cognitive behavior therapy, therapeutic foster care as defined by the Oregon Social Learning Center, and specialized training for the foster parents of infants and pre-school children all have good evidence of efficacy in this population (10, 11, 12, 13). However, neither Medicaid nor child welfare have strategically re-directed the funds available for mental health to provide incentives for the adoption of these modalities. Medicaid does, however, fund psychotropic medication use.
There was at least one very positive finding in the current study. Over 90% of children and youth in foster care who were on psychotropic medication had received their prescriptions from a psychiatrist. The AAP (14) and the Child Welfare League of America (15) have long recommended that all children and youth entering foster care have access to mental health evaluation. While the time frame is unclear, the data in this study indicate that this population had significant access to mental health care, for which child welfare should be congratulated in this particular state.
In this study, the discrepancy between psychotropic medication prescriptions for Caucasian or Hispanic children versus African-American children suggests either that the latter have a lower burden of mental health problems or, more likely, less access to needed services. Unfortunately, most studies have shown that the latter is more often the case (16).
The AAP recommends that medications, psychotropic and otherwise, be studied more fully in children, so that we have a clearer understanding of their benefits and risks (17). The data from this article support the need for more thorough investigation of the use of psychotropic agents in children and youth in foster care. However, children and youth in foster care also need access to mental health evaluation by well-trained pediatric mental health professionals, access to evidence-based mental health interventions, well-trained and supported foster parents and caseworkers, and access to a pediatric medical home. Medication is ONE of the interventions we need to consider, but it should not be the first one and it should never be the only one. A centralized Pediatric medical home in our community is associated with improved mental health access, with 70% of children and youth in foster care having access to mental health services (18). A medical home provides a level of oversight and coordination for health care that is often lacking for children in foster care. It should be noted that the state of Texas, where this study originated, has developed stringent guidelines for the administration and oversight of psychotropic medications in the foster care population. However, timely access to specialized health and mental health services, particularly for those children whose needs appear to exceed typical “guidelines for care” is critical. The AAP and CWLA have long recommended the development of centralized health and mental health administrative structures within child welfare systems to support case workers and foster parents, and to ensure that children in foster care receive appropriate medical and mental health care and follow up services. Finally, birth parents should also have access to evidence-based mental health services, drug and alcohol rehabilitation services, and evidence-based parenting interventions, because the well-being of the child and the possibility of reunification with the biological family depends mostly on the improved functioning of the parents. References 1. Zito JM, Safer DJ, Devadatta S, Gardner JF, Thomas D, Coombes P, Dubowski M, Mendez-Lewis M. Psychotropic medication patterns among youth in foster care. Pediatrics. 2007;121:e157-e163
2. Simms M, Dubowitz H, Szilagyi MA. Health care needs of children in the foster care system. Pediatrics. 2000;106:909-918.
3. Stahmer AC, Leslie LK, Hurlburt MS, Barth R, Webb MB, Landsverk JA, Zhang J. Developmental and behavioral needs and service use for young children in child welfare. Pediatrics. 2005;116:891-900.
4. Burns BJ, Phillips SD, Wagner HR, Barth R, Kolko DJ, Campbell Y, Landsverk JA. Mental health need and access to mental health services by youths involved with child welfare: A national survey. J Amer Acad of Child Adolesc Psychol. 2004;43:960-970.
5. Leslie LK, Hurlburt MS, Landsverk JA, Barth RP, Slymen DJ. Outpatient mental health services for children in foster care: A national perspective. Child Abuse Negl. 2004;28:697-712.
6. Fisher PA, Gunnar MR, Dozier M, Bruce J, Pears KC. Effects of therapeutic interventions for foster children on behavioral problems, caregiver attachment, and stress regulatory neural systems.
7. Fisher PA, Burraston B, Pears K. The early intervention foster care program: permanent placement outcomes from a randomized trial. Child Maltr. 2005;10:61-71. 8. Fanshell, D., & Shinn, E. Children in Foster Care: A Longitudinal Investigation. New York: Columbia University Press . 1978. 9. Horwitz SM, Balestracci KMB, Simms MD. Foster care placement improves children’s functioning. Arch Pediatr Adolesc Med. 2001;155:1255-1261.
10. Stambaugh L, Burns BJ, Landsverk J, Reutz JR. Evidence-based treatment for children in child welfare. Focal Point. 2007;21:12-15.
11. Marsenich L. Evidence-based practices in mental health services for foster youth. California Institute for Mental Health. Sacramento, CA. 2002.
12. Dozier M. Developing evidence-based interventions for foster children: An example of a randomized clinical trial with infants and toddlers. J Soc Iss. 2006;62:767-786.
13. Landsverk JA, Burns BJ, Stambaugh LF, Reutz JAR. Mental health care for children and adolescents in foster care: Review of the research literature. Casey Family Programs. 2006.
14. American Academy of Pediatrics. Fostering health: Health care standards for children and adolescents in foster care. Task Force on Health Care for Children in Foster Care. District II, NY. 2005.
15. Child Welfare League of America. Standards of excellence for health care services for children in out-of-home care. Washington, DC. 2007.
16. Garland AF, Hough RL, Landsverk JA, McCabe KM, Yeh M, Ganger WC, Reynolds BJ. Racial and ethnic variations in mental health care utilization among children in foster care. Children’s Services. 2000;3:133 -146.
17. Vitiello B. Psychopharmacology for young children: Clinical needs and research opportunities. Pediatrics. 2001;108:983-989.
18. Jee SH, Szilagyi M, Blatt SD, Meguid V, Auinger P, Szilagyi PG. Timely identification of mental health needs in two foster care medical homes. Manuscript in process.
Conflict of Interest:
None declared