If you are a foster child getting medications for emotional and mental health issues in the United States you may be getting more than you need. A 2011 report by the Government Accountability Office (GAO) showed that foster children in five surveyed states “were prescribed psychotropic drugs at rates 2.7 to 4.5 higher than were nonfoster children in Medicare in 2008” (GAO-12-270T). This was true for all three age ranges examined, from birth to age 17. In a follow-up 2012 GAO nationwide survey, 18 percent of foster children were taking at least one psychotropic medication (GAO-14-651T). Many were taking multiple medications concurrently.
One major reason for this problem is polypharmacy, or the use of multiple medications by a single patient, often to treat the same condition. Approximately 13 percent of foster children who are prescribed psychotropic medications are taking at least three different drugs (GAO-14-651T).
In 2014, the GAO enlisted two child psychiatrists to review the cases of several dozen foster children who were taking psychotropic medications. The doctors found that the use of medications was often not entirely supported by the documentation accompanying the child’s case and was less frequently supported in cases of concurrent use (GAO-14-362).
To help address this issue, the American Academy of Child and Adolescent Psychiatry (AACAP) crafted a set of best principle guidelines covering four main categories: consent, oversight, consultation, and information. Each state is given the authority to craft their own policies, consistent with issues of youth and family services being handled on a state level. Yet in every state reviewed by the GAO in 2014, the states’ monitoring programs “fell short of best-principles guidelines published by the AACAP” (GAO-14-362).
We need to do better. Each state needs to do an in-depth comparison of its monitoring programs in relation to the AACAP guidelines. Any areas where a state falls short—most likely oversight and the provision of information—should be examined for feasible improvement plans.
Oversight includes monitoring the rate at which medications are prescribed. Information reform includes improving family access to medication information and improving communication between doctors caring for the same child so care can be streamlined. Electronic medical records, for example, are growing increasingly common in both office and hospital settings and allow for a patient’s complete medical history to be sent to a healthcare provider with relative ease.
Before any meaningful policy reform can take place, there will need to be extensive research on current state protocols and efficacy. Though this is costly and time consuming, the long-term benefits could be significant, including a reduction in the use of medications by foster children. Additionally, a decrease in the amount of psychotropic medications prescribed to children whose healthcare is a responsibility of the state could result in significant savings in program costs.
Medical care for foster children is financed by Medicaid programs, which rely on both state and federal funding, so governments at both levels would benefit financially from a reduction in the use of psychotropic medication. A 2011 GAO study found that five states surveyed in 2008 “spent over $375 million for prescriptions provided through fee-for-service programs for foster and nonfoster children” (GAO-12-270T). The report calculated that these states spent approximately $59 million on psychotropic medications for foster children.
As of 2014, Pennsylvania had 14,840 children in its foster care system (GAO-14-362). These children are the responsibility of the state, both financially and morally, so it’s important that the Philadelphia Department of Human Services review the psychotropic medication policies of Pennsylvania and search for failings in the delivery of psychiatric care. The results of the review could increase efficiency and cost-effectiveness as well as improve outcomes.
The large scope of foster care issues and the obvious shortcomings that have resulted from a lack of standardization have led many to support the institution of national standards in foster care. Several years ago, the GAO recommended that the U. S. Department of Health and Human Services (HHS) create guidelines for how states could oversee the prescription of psychotropic medications to foster children. HHS reportedly agreed with the recommendation for the creation of national guidelines. However, states still have largely different guidelines in place. Even more troubling is the incomplete documentation many states have on the medication compliance of the children or their outcomes.
Whatever national policy is implemented to ensure that states meet a certain threshold, they will have to research the outcomes of their current practices and make adjustments to comply. Working to improve a state’s handling of this important issue as soon as possible will best prepare the state for coming changes.
Emily Rose DeMarco
Emily Rose DeMarco is a Masters of Public Administration candidate at the University of Pennsylvania’s Fels Institute of Government. She is also a registered nurse currently working in emergency medicine.