Reducing Psychotropic Prescriptions Requires Systemic Reform

The over-reliance on psychotropic medication for children in foster care has been drawing a lot of attention both among policymakers and in the media. A recent study reports that in 2012, Pennsylvania’s foster children were nearly three times as likely to be prescribed psychotropic drugs for behavior problems as other children on Medicaid.

Proposals before Congress and various state legislatures attempt to address the excessive use of psychotropic drugs for foster children. But it is important to recognize that over-reliance on psychotropic medications is a symptom of larger problems.

In my five years as a foster care social worker in the District of Columbia, I saw several young people who were given too many psychotropic medications. In every one these cases, serious and general problems with the foster care system played a significant role.

One such problem is the lack of involvement of many foster parents in the care provided to their charges. In my practice as a social worker, it was very rare for foster parents to take children to the psychiatrist. The foster parent was not there to tell the psychiatrist what the child’s symptoms were, or how the child was responding to the medication already prescribed. Instead the social worker, with far less detailed information, was the liaison between the foster family and the psychiatrist.

Most foster parents did not take their child to the psychiatrist because they worked full-time and expected the social worker to take their children to appointments. “Real parents” know they have to take off from work for this purpose. If more foster parents treated their foster children as their own, there would be less reliance on inappropriate psychotropic medications.

Foster parents need to be part of a vigorous treatment team including the psychiatrist, therapist, social worker, Guardian ad Litem, and birth parent. Such a strong team, with the foster parent fully on board, is one way to prevent inappropriate medication. As I’ve argued before, in order to make sure foster parents are willing and able to do this for children with special needs, they need to be paid as professionals for whom parenting is a full-time job.

A major investigative report of California’s system found that of the 3,800 youths living in group homes, more than half were authorized to receive psychotropic drugs. One reason for this may be that group homes are serving the most troubled youth. But any group home relying on medication as a means of control rather than treatment clearly has serious problems.

Poor mental health care for Medicaid recipients is another root cause of the overuse of psychotropic medications. Because Medicaid reimbursement rates are so low, the quality of psychiatric services delivered through it is notoriously poor. One Medicaid psychiatrist would write my client’s prescriptions as we were walking into the office. She had no intention of talking to her patient before we left with the prescriptions, even though Medicaid was being billed for an office visit.

Another psychiatrist insisted on prescribing medication to a patient even though she had been doing well without it. He expressed the fear that in the absence of medicine, the judge on the case would blame him for any misbehavior by the client.

A reduction in the use of medication requires an increased reliance on therapy. President Obama’s plan to reduce psychotropic medications supports state efforts to come up with alternative, evidence-based practices such as trauma-informed therapies. But in the absence of increased Medicaid reimbursement rates, these new therapies will be administered mainly by poorly-reimbursed providers.

Because the poor quality of Medicaid therapists is widely recognized, the District of Columbia contracts with other providers to provide therapy to a small number of clients, the most troubled ones. But most foster children have to rely on mediocre Medicaid therapists.

In order to address the overuse of medication, we need to recognize the broader problems that contribute to it. It makes sense to monitor medication use among foster children and target group homes or psychiatrists who are out of line in their use of medication.

But adding layers of review without addressing the root causes of the problem might just reduce the amount of medication children receive. It will do nothing to ensure they receive the appropriate treatment to meet their needs.

Marie K. Cohen is a former child welfare caseworker for Washington, D.C. She previously worked as a policy analyst and researcher at the U.S. Government Accountability Office, the Welfare Information Network, the Center for Law and Social Policy and the University of Maryland Welfare Reform Academy.

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Marie K. Cohen
About Marie K. Cohen 68 Articles
Marie K. Cohen (MPA, MSW) is a child advocate, researcher, and policy analyst. She worked as social worker in the District of Columbia's child welfare system for five years. She is a member of the Citizen's Review Committee for the DC Child and Family Services Agency and the DC Child Fatality Review Commission and a mentor to a foster youth. Follow her blog at fosteringreform.blogspot.org, on Facebook at Fostering Reform or on Twitter@fosteringreform.

7 Comments

  1. Seems the foster parents are happy with subsides they get from having “handicap” children but they can’t be bothered to take them to their appointments but they knew it would be like this when they signed up for it. Looks like foster parents treat social workers like concierge just for them.

  2. oh yeah, let’s jump from topic to topic and avoid the real problem. It may be systemic but it’s the social worker who’s making the referral to the shrink. Make them STOP and do their jobs and quit paying jerk shrinks to see our children for 15 minutes and drug them for years. Everyone knows your greedy industry is drugging children to make more money for themselves and screw the children.

    • Ummmm…perhaps you didn’t realize that in fact few child welfare organizations actually employ real social workers?! (Msw or bsw w/ licensure.). Perhaps if we valued real professionals doing the work, it would improve.

      In the meantime, you may want to educate yourself about the credentials required to work in child welfare.

      And as Marie pointed out (surprised you missed it? It was pretty clear) ‘real’ parents take their children for medical care and are involved with the provision of care.

    • Ummmm…perhaps you didn’t realize that in fact few child welfare organizations actually employ real social workers?! (Msw or bsw w/ licensure.). Perhaps if we valued real professionals doing the work, it would improve.

      In the meantime, you may want to educate yourself about the credentials required to work in child welfare.

      And as Marie pointed out (surprised you missed it? It was pretty clear) ‘real’ parents take their children for medical care and are involved with the provision of care.

      Finally, how ironic that you are criticizing the child welfare caseworkers for pursuing entail health care while others criticize them for NOT seeking care.

      Which one is it? Are they engaging foster chhildren in treatment too often or too infrequently? How would you know if it was just the right amount???!!!

  3. 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.

    http://citylimits.org/2014/06/06/are-we-overmedicating-kids-in-foster-care/

    • I agree, especially about the Medicaid mills. Interesting point on the compensation issue. I had not seen that in my practice. It was the diagnosis, rather than the medication, that drives the classification of a foster child as therapeutic. But you are right that medication should not be used to avoid managing the behaviors. It is horrifying that medication would be prescribed to a 2 1/2 year old. Thanks for your comment.

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