A recent study reported in the Journal of Child and Adolescent Psychopharmacology reveals that one third of children in foster care diagnosed with ADHD have been treated off-label with an atypical antipsychotic medication. As a parent, would you consent to your child being prescribed an atypical antipsychotic medication? I submit that the label alone should raise alarm.
Atypical antipsychotic medications are major tranquilizers and neuroleptics used to treat psychiatric conditions. Some atypical antipsychotics have received regulatory approval for adults for conditions such as schizophrenia, bipolar disorder, dementia, autism, obsessive compulsive disorder and major depressive disorder. Most atypical antipsychotics are not approved by the Food and Drug Administration for use by children. But they can legally be used off-label, which means the drug can be prescribed to treat a condition for which it does not have FDA approval.
These medications can cause troubling side effects in adults, including muscle rigidity, slow movement and involuntary tremors resembling Parkinson’s Disease, as well as substantial weight gain, among other things. Because of the small body of evidence about the use of atypical antipsychotics by children and teenagers, it’s difficult to determine their short term effectiveness and safety. And little is known about their long-term safety and efficacy due to the dearth of studies on this topic.
Little is also known among many of the professionals prescribing these drugs about the mental-health impact of entering foster care. When children are initially removed, those who have experienced trauma as a result of removal and the abuse or neglect they suffered in the home will respond in various ways and, thus, there is no uniform means of identifying a traumatized child. For example, some children may suppress their feelings to protect themselves from further disappointment and rejection; others may outwardly misbehave, possibly because that is what they believe is expected of them or because they believe this act of sabotage will allow them to return home. Simply put, it may, in fact, be very difficult to identify from the child’s outward behavior whether a child is experiencing trauma. In addition, services often center on correcting the child’s behavior in the foster home as reported by the foster parent. As a result, the behaviors are addressed without identifying and treating the root cause.
It is undisputed that children in foster care have a disproportionately high prevalence of mental health disorders. In New York City studies have shown that a large majority of children in foster care have a mental health problem serious enough to warrant treatment, yet most remain undiagnosed and untreated or, if they are detected, they are over- or irresponsibly medicated. Moreover, even children who have a diagnosis in foster care do not receive adequate or appropriate mental health services. Even for those families who access mental health treatment, they are generally restricted to one of many “Medicaid Mills” which are in the business of processing as many patients as possible. Assuming they are given a block of time, they are frequently faced with practitioners (frequently interns) who simply do not understand the dynamics of foster care and adoption and who cannot offer successful treatment and interventions. In addition, foster parents simply seek a quick fix to address what they perceive to be disruptive behaviors in the home. As a result, situations like this where foster children are medicated with atypical antipsychotics arise.
There is action on a national level to address the issue. The PsychDrugs Action Campaign, an initiative of the National Center for Youth Law in Oakland works collaboratively with former foster youth, their advocates, and state agencies to develop more effective regulation of psychotropic medication for foster children and improved access to alternative treatments. By publicizing progress in states such as Florida, Texas, Georgia, Ohio, and California, the PsychDrugs Action Campaign seeks to help all the states to adopt reforms that are being developed in the most progressive states. For example, in Ohio they are using Pharmacy Benefits Claims data to identify the most dangerous prescribing practices and using psychiatric consults and supports to review the children’s cases and the prescribers’ progress towards safer prescribing. Particularly in those situations where psychotropic medications were prescribed to children under age of 6, where children were prescribed two or more antipsychotics for more than 60 days, or where children were prescribed four or more psychotropic medications concomitantly. In Texas, a recent law requires that kids who've been prescribed medication be seen by their prescribing physician at least every 90 days and requires that judges overseeing a child's foster care case be informed of behavioral and pharmacological treatments at all court hearings.
Unfortunately, New York has not yet responded as other states have with proposed and enacted reforms. The Administration for Children’s Services has issued guidelines encouraging physicians to “start low and go slow.” According to an ACS “Quality Assurance” document, the prescribing psychiatrist must document his “reasons for prescribing the medication; name and dosage of medication and the date prescribed; previous non-pharmacological interventions; and expected results of the medication and potential side effects.” Promisingly, a Psychotropic Medication Committee is currently being formed to provide further guidance in this area for ACS.
We need to raise consciousness inside the local child welfare community and beyond. Potential financial motives must be recognized: Psychotropic medication usually elevates the child’s classification from a “basic” rate to “special” or “exceptional,” a change accompanied by a significant increase in financial compensation. Motivations in reporting of foster children’s behaviors must be closely examined not only for financial incentives but also for practitioners taking the easy way out in terms of managing the behaviors. In reviewing records our office has seen a child as young as 2-and-a-half medicated with an atypical antipsychotic for “disruptive, unpredictable, and aggressive behavior.” Emphasis must be placed on identifying and securing quality and consistent mental health services for children in foster care outside of the standard “Medicaid Mills” to provide for comprehensive treatment plans for children including therapy, parent-management training and specialized educational programs for biological and foster parents. And individuals like me, a member of the court community, must educate themselves about these drugs and seek to intervene if necessary with the legal tools available to us.
We need to do better for our foster children.
The views expressed are those of the author and not the organization.