In a 2004 report titled “Forgotten Children” that highlighted the overuse of psychotropic medication by foster children in Texas, then-state Comptroller Carole Keeton Strayhorn wrote of a foster child who was prescribed 11 medications in one month, including two antidepressants and two stimulants to treat ADHD, at a cost of $1,088 to the state’s Medicaid program.
Since that critical report, Texas has instituted massive reforms. And though the changes have improved the state’s health care system for foster children, child welfare advocates say, the rate of foster kids prescribed psychotropic drugs remains high, and accountability gaps regarding prescriptions of the psychiatric medicines persist.
“So the child isn’t putting his fist through the wall, but he can’t concentrate in school and he’s drooling and his hand’s shaking,” said Katherine Barillas, director of child welfare policy with One Voice Texas, a collaborative of Texas human service organizations, adding that many health care providers are “observing this behavior in children who are in foster care that they interact with and they’re wondering why no one else is noticing.”
The rate of foster children prescribed psychotropic drugs has dropped from 42 percent in 2004 to 32 percent in 2012. During that time the population of foster children grew from 27,400 to 47,900, and the overall number prescribed psychotropic medications increased as well, from 10,850 to 15,250.
These graphs show how the rate of foster children prescribed psychotropic medicines has declined since 2004. You can choose age groups to add to or subtract from each graph.
“We have made a lot of progress and continue to have a sharp eye on the use of psychotropics,” Patrick Crimmins, a spokesman for the Texas Department of Family and Protective Services, said in an email. He emphasized that the state’s efforts have reduced the rate of foster children using psychotropic drugs for more than 60 days — a better indicator of refilled prescriptions — from 29.9 percent in 2004 to 20.8 percent in 2012.
The state reformed the system by placing all foster children in a single Medicaid managed care organization, STAR Health, which set up a “health passport” system to track the children’s medical histories. A variety of parameters are documented in the STAR Health medical passports to monitor foster children’s use of psychotropic medications, which if triggered alert the state to check on the child.
Crimmins gave four examples of foster children who have received psychotropic medications: a newborn who suffered from heroin withdrawals; a 7-year-old girl whose mother prostituted her and who would run away, undress publicly and hit people; an 11-year-old girl who would unplug other children’s medical equipment and assault children in wheelchairs; and a 15-year-old girl who was beaten and forced to sleep in the yard so long that she began acting like an animal and had trouble speaking.
There are multiple classes of psychotropic drugs, including antidepressants, antipsychotics, sleep medications and antianxiety medications. The state’s monitoring parameters will raise a red flag if a foster child is prescribed two medicines from the same class or five or more psychotropic medications from any class to take at the same time. They’ll also alert the state if a child is prescribed a psychotropic medication for more than 60 days without receiving a clinical mental health diagnosis. These graphs show the number of foster children who were identified by the state’s monitoring parameters. You can click on an age group to add it to each graph or to remove it.
The Number of Foster Children: Prescribed Multiple Psychotropic Medications in the Same Class | Prescribed Five or More Psychotropic Medications of Any Class | Prescribed Psychotropic Medication for 60+ Days Without Mental Health Diagnosis
In 2011, the U.S. Government Accountability Office released a report that found Texas had the second-highest rate of foster children prescribed psychotropic drugs — at 32.3 percent — behind Massachusetts but ahead of Florida, Michigan and Oregon. The states were chosen for analysis based on their geographical diversity and sizable foster care population.
Dr. William Streusand, a psychiatrist who works with foster children as the medical and executive director of CollaboraCarein Austin, said all foster children face some trauma, and that a scarcity of alternative treatment options like trauma-based therapy lends to the widespread use of psychotropic medications.
“I do see kids I think are overmedicated, but the way these things happen aren’t necessarily badly intentioned,” he said, explaining a pharmaceutical regime may be built up over time for older children in the foster care system if the child is moved multiple times and treated by different psychiatrists, or if existing medication stops being effective. He also said the shortage of child psychiatrists in Texas means many foster children are treated by well-intentioned, if misguided, psychiatrists used to prescribing higher doses for adults.
Streusand also expressed concerns about the state’s health passport accountability system, which he said often lacks important medical information that could help psychiatrists determine medications. “I’ve never actually had someone call me for a review of the medicines I’m writing,” he added.
Barillas of One Voice Texas, who has 15 years experience working in child welfare, said the bar for using such medicine should be higher.
“Many in the advocacy community would probably say that that list of compelling reasons [to put toddlers on psychotropic medications] would probably or should be incredibly short,” Barillas said.
Barillas added that Texas’ health passport system has become a model for accountability in other states, but that lawmakers could pass additional requirements to improve accountability, such as strengthening informed consent rules to ensure foster parents and social workers understand the implications and side effects of giving children psychotropic medications, and requiring in-person check-ups with psychiatrists every 90 days for foster children using such medications.
Currently, those checkups can be done over the phone, which, she said, makes it difficult for the psychiatrist to evaluate the physical side effects of the drugs.
“I think there’s kind of a lack of realism about what the lives of these children have been like, what they’re grappling with and how difficult it is to treat them,” said Scott McCown, executive director of the left-leaning Center for Public Policy Priorities. He said some of the policies child welfare advocates have proposed, like requirements for informed consent or trying nonpharmaceutical interventions first, may interfere with children’s overall well-being and stop the already short supply of psychiatrists from agreeing to treat these children.
The state is also in the midst of redesigning the foster care program to help children stay with siblings and near their home community, which could address some of the problems Streusand and advocates have identified.
“The entire concept of foster care redesign is to remake the system so that these children get better care,” Crimmins said. The same safeguards will be in place, “but our hope and expectation is that all of these improvements will translate into a reduction in the use of psychotropic medications.”