Behavioral health challenges are one of the many barriers to permanency that children in out-of-home-care face. In many instances, they may be prescribed psychotropic medications to address these challenges. Research has found that children in out-of-home care are prescribed psychotropic medication at a higher rate than those in the general population (17.7% vs. 6%).1 This disparity raises the question of whether children in out-of-home care are prescribed medication in excess of what is required to adequately meet their needs or whether the population in general presents with more challenges. Whether addressing real medical needs or making decisions about excess in prescribing, the safety of every child in out-of-home care depends on being prescribed the proper dose of the correct medication(s) for the indicated time period.
Given this rate of medication use by children in out-of-home care as well as the potential impact on safety, it is important for agencies to have policies that provide effective oversight. According to a review of the statutes and policies regarding psychotropic medications for children in out-of-home care in 16 states,2 researchers were unable to locate many of the policies that had been reported in other studies. When policies did exist, they were “extremely underdeveloped and failed to include many of the ‘red flag’3 criteria that both experts and states identified as essential to protecting children.”4 As a result, ensuring effective oversight and monitoring has been an area of focus for federal, state, and local policymakers and stakeholders alike.
Improving oversight of psychotropic medication use
In response to the heightened focus on monitoring use of psychotropic medication, in 2011, a new requirement was mandated in the Child and Family Service Improvement and Innovation Act (P.L. 112-34) requiring states to include a psychotropic medication oversight plan in their State Child and Family Service Plans. Following the new law, three publications addressed the complexities of and the best practices for establishing or improving psychotropic medication oversight plans. In 2012, the Children’s Bureau (CB) issued the information memorandum, Promoting the Safe, Appropriate, and Effective Use of Psychotropic Medication for Children in Foster Care,5 outlining steps that states should take to monitor the safety of children in foster care placed on psychotropic medications. Subsequently, the Center for Health Care Strategies (CHCS), with support from the Annie E. Casey Foundation, worked with six states6 from 2012 to 2015 as part of the Psychotropic Medication Quality Improvement Collaborative.7 The collaborative developed tools and guidance for stakeholders to ensure that children prescribed psychotropic medications receive appropriate screening, assessment, treatment, and monitoring. In 2015, the American Academy of Child and Adolescent Psychiatry (AACAP) updated guidelines related to the safe and appropriate use of psychotropic medications for children in foster care, which many child welfare jurisdictions have since used and adapted. These guidelines, Recommendations about the Use of Psychotropic Medications for Children and Adolescents Involved in Child-Serving Systems,8 called on state child welfare agencies to create monitoring and oversight systems to ensure safety in the administration of prescription medication.
Framework for monitoring the use of psychotropic medications
Given the high rate of psychotropic medication use by youth in out-of-home care, it is important for child welfare leaders to establish an effective psychotropic medication oversight plan. The recommendations outlined by the three publications above provide guidance in several crucial areas. Combined, these areas create a five-item framework that child welfare leaders can use to guide the development of effective oversight policies for the use of psychotropic medication by children and youth in out-of-home care.
Screening, assessment, and treatment planning
- Develop coordinated efforts to identify children’s mental health and trauma treatment needs. Agencies should administer a comprehensive assessment, including a psychiatric evaluation, in the event that psychotropic medication is needed (CB).
- Provide case workers and providers access to decision-making, service planning, and outcomes monitoring tools (CHCS).
- Ensure that prescribers of medication adhere to a developmentally informed biopsychosocial approach, trauma informed care principles, and system of care principles. Provide youth with behavioral health needs a combination of psychosocial interventions and medication (when indicated) (AACAP).
Consent and assent
- Implement methods for informed and shared decision-making and communication between the child, the prescriber, caregivers, healthcare providers, child welfare workers, and other key stakeholders (CB).
- Implement agency consent that requires a secondary review of all the psychotropic medications prescribed to children involved in child welfare. These requirements vary by state but can help prevent inappropriately prescribing medication (CHCS).
- Ensure prescribers interact with the children and families to whom they are prescribing medication as well as any systems in which the families are involved. Medication review processes should be streamlined to prevent treatment delay (AACAP).
The factors below have been found to influence the likelihood of being prescribed psychotropic drugs among children in out of home care:9,10
- Age – Children in foster care are more likely to be prescribed psychotropic medications as they get older. They are also more likely to be prescribed multiple psychotropic medications.
- Gender – Males are more likely than females to be prescribed psychotropic medications.
- Behavioral concerns – Children scoring in the clinical range on the Child Behavioral checklist are more likely than those with subclinical scores to be prescribed psychotropic medications.
- Placement type – Children in more restrictive placement types are more likely to be prescribed psychotropic medications and be prescribed more than one.
- Geographic variation -There are significant geographic variations in the prescribing of psychotropic medications that cannot be attributed solely to population differences.
Psychiatric expertise and consultation
- Ensure availability of board-certified or board eligible child and adolescent psychiatrists for expertise regarding consent and monitoring issues (CB).
- Verify that primary care providers (who are often relied on for determining treatment for children involved with child welfare) are able to consult with behavioral health care experts (CHCS).
- Implement consultation programs that can offer case review and second opinions when needed. These programs should have access to child and adolescent psychiatrists (AACAP).
Data, monitoring, and Continuous Quality Improvement (CQI)
- Implement medication monitoring at both the agency and child/family level (CB).
- Establish state-level consensus on the type of data collected related to prescribing patterns. Consider including name of child, condition being treated, type of medication, dose, and prescribing clinician (CHCS).
- Include the participation of child and adolescent psychiatrists in the development of monitoring and oversight standards. Collaborate with state and local agencies and managed care providers and encourage the use of evidence-informed practice. Encourage multiple methods of oversight (e.g., review of aggregate data, chart audits, tracking of red flags) (AACAP).
Guidance, education, and information sharing
- Disseminate information and educational materials about mental health and trauma-related interventions with caseworkers, clinicians, children, and their families (CB).
- Facilitate an understanding by children, their families, caseworkers, and other providers of what each medication is for, how it is used, and its potential effect to encourage appropriate use (CHCS).
- Encourage providers to promote awareness of the potential adverse effects of the medication(s) and to monitor for side effects (AACAP).
Given the high rate of psychotropic medication use by youth in out-of-home care, it is important for child welfare leaders to establish an effective psychotropic medication oversight plan. The plan should outline a coordinated approach that clearly defines the role of each person involved in the prescribing process. The five-item framework can guide child welfare leaders who are interested in implementing new policies or ensuring that their existing policies align with best practices. More detailed guidance, as well as additional background information, can be found in the three publications discussed above.
1 Stambaugh, L.F., Leslie, L.K., Ringeisen, H., Smith, K., & Hodgkin, D. (2012). Psychotropic medication use by children in child welfare (OPRE Report #2012-33). Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. Retrieved from https://www.acf.hhs.gov/sites/default/files/documents/opre/psych_med.pdf
2 These 16 states account for 72% of all children in care nationally.
3 Markers used in audits, case reviews, or databases located within child welfare, Medicaid, mental health, and managed care plans to identify cases in which available data suggest medication use may not be appropriate.
4 Noonan, K. & Miller, D. (2014). Fostering transparency: A preliminary review of ‘policy’ governing psychotropic medications in foster care. Hastings Law Journal, 65. Retrieved from: http://www.hastingslawjournal.org/wp-content/uploads/Noonan-65.6.pdf
5 Administration for Children and Families. (2012). Information memorandum: Promoting the safe, appropriate, and effective use of psychotropic medication for children in foster care (ACYF-CB-IM-12-03). Washington, DC: Administration on Children, Youth and Families, U.S. Department of Health and Human Services. Retrieved from https://www.acf.hhs.gov/sites/default/files/documents/cb/im1203.pdf
6 The six states that participated were: Illinois, New Jersey, New York, Oregon, Vermont, Rhode Island.
7 Center for Health Care Strategies. (2014). Psychotropic medication quality improvement resources. Retrieved from https://www.chcs.org/resource/psychotropic-medication-quality-improvement-resources-2/
8 American Academy of Child & Adolescent Psychiatry. (2015). Recommendations about the use of psychotropic medications for children and adolescents involved in child-serving systems. Retrieved from https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/systems_of_care/AACAP_Psychotropic_Medication_Recommendations_2015_FINAL.pdf
9 Children’s Bureau. (2012). Oversight of psychotropic medication for children in foster care: Title IV-B health care oversight and coordination plan. Retrieved from: https://www.acf.hhs.gov/sites/default/files/documents/cb/im1203.pdf
10 California Social Work Education Center. (2015). Literature review: Psychotropic medication and children and youth in foster care. Retrieved from: http://calswec.berkeley.edu/sites/default/files/uploads/psychotropic_medication_children_youth_foster_care_lit_review.pdf