Reducing Psychotropic Medications 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.

This column was published in the Chronicle of Social Change on July 13, 2015.

Confidentiality Should Not Apply When a Young Child Disappears

On March 19, 2014, a school social worker in Washington, D.C. went to a homeless shelter to obtain a doctor’s note for a student. Eight-year-old Relisha Rudd had been absent from her classroom for almost three weeks without a written excuse. Her family had told school staff that Relisha was ill and under the care of a “Doctor Tatum.”

But when the social worker arrived at the shelter, he discovered that the supposed “doctor” was a janitor and the child was missing. This touched off a frantic hunt for the missing child, who was last seen on March 1.

Tatum, who police believe shot and killed his wife, was found dead of an apparent suicide in a park. Over a year later, the child has not been found and is feared dead. But despite the real fear that this young girl will never be found, records that could shed light on what happened here are being kept confidential.

Relisha’s case has been portrayed as a failure of the District’s crumbling family homeless shelter. To a secondary degree, the school has been held responsible for failing to report Relisha’s absence earlier to the Child and Family Services Agency (CFSA). But the role of CFSA itself in this tragedy has received little attention.

Relisha’s family was known to CFSA. Not only had the family been the subject of several reports of abuse or neglect, but the most recent occurred only a few months before Relisha disappeared. The Washington Postreported that “a social worker noted a lack of supervision and abuse.” Unfortunately, the Post’s coverage did not clarify whether CFSA opened a case to provide services and supervision.

According to the Post, there were numerous indications that the family was in trouble. Relisha’s brothers had frequent behavior problems at school. School staff reported numerous warning signs, such as Relisha missing over 30 days of school and often showing up dirty, and Relisha and her brother waiting for a ride long after other children had left school.

If a case was open, then a social worker was required to see all the children at least twice a month. If there was no open case, then the question is: Why not?

The backdrop to this story is the dramatic decline in the District of Columbia’s foster care caseload: the number of children in care has decreased from 2,007 at the end of 2010 to 1,068 at the end of 2014. CFSA has been touting the success of its initiative to take fewer children into foster care. About 62 percent of its clients are now being served in-home.

That is good news indeed, as long as the children remaining with their families are receiving the monitoring and services that they need to be safe. However, Relisha’s story suggests that may not be the case.

Children who are remaining at home with their families are not receiving adequate services, according to the Center for the Study of Social Policy (CSSP). CSSP monitors child welfare services for the court. Of the cases CSSP reviewed where a child
was receiving in-home services, “only 25 percent were rated as acceptable on ‘Implementing Supports and Services.’”  Moreover, only 30- to 51 percent of the cases reviewed each month had documentation that safety was fully assessed at two or more visits as required by the court. These results give reason to wonder how many potential Relishas are currently out there.

Unfortunately, confidentiality laws prevent the release of information that would let us know how the system broke down in Relisha’s case. The Child Abuse Prevention and Treatment Act (CAPTA) requires that states preserve the confidentiality of child abuse reports and records except in the case of a fatality or near fatality. A “near-fatality” is currently interpreted to be an act that puts the child in serious or critical condition.

But remarkably, a young child who has been missing for over a year does not qualify as a “near fatality.” And citing confidentiality, CFSA has refused to issue any details about its handling of Relisha’s case. Instead, the agency posted a report on its interactions with Relisha Rudd and her family with large sections redacted. Many of these omissions appear to imply that there were gaps in the services provided by agencies including CFSA.

We cannot rely on child welfare agencies to take the necessary measures to prevent tragedies like Relisha’s in the absence of external scrutiny. CAPTA should be changed to require states to release otherwise confidential information in cases where children have been missing for some time and there is substantial reason to believe they are dead.

The safety of children in the system must take precedence over the right of confidentiality. Less than a month ago, volunteer divers were again searching the Anacostia River for Relisha’s body. The citizens of the District should not have to depend on the finding of her body in order to learn whether the government tried to protect her while she was alive.

This column was published in the Chronicle of Social Change on July 7, 2015. 

Educational Stability, Normalcy Best Served by Closer Placements

In the past, the trauma of being placed in foster care was often intensified by placement in a new school. But in 2008, Congress passed the Fostering Connections to Success and Increasing Adoptions Act, which required that a child who is placed in foster care (or in a new foster home) remain in the same school unless it is not in his or her best interest.

But as reported in The Chronicle of Social Change last week, implementation has been hampered by the lack of cooperation from schools. In response, Sens. Al Franken (D-Minn.) and Chuck Grassley (R-Iowa) have introduced a bill to improve education stability for kids in foster care by enhancing collaboration between child welfare agencies and schools.

Fostering Connections made a big difference, at least in the District of Columbia where I worked as a social worker. The first thing we used to do when a child came into care was to register him or her at a new school near the foster home, which was usually in Maryland. With the implementation of Fostering Connections, we were suddenly making arrangements to have our clients transported to their current school in D.C.

This change in practice was positive for many foster children. My first client to benefit was attending a high-performing charter school in the city. Rather than putting her in the low-performing school in the neighborhood of the foster home, we were able to transport her to her school, which was a great source of stability and support for her.

However, in many cases, school stability conflicts with another value that is currently gaining great currency: that of “normalcy” for foster children. Following the lead of several states, Congress recently enacted a law last year that requires states to allow foster children to engage in “extracurricular, enrichment, cultural and social activities.”

But when young people have long commutes that require private transportation, it is often difficult or impossible for them to participate in activities and visit friends. In many urban areas, children removed from families in the inner city go to foster homes in the suburbs because there are not enough foster families in central cities.

Over half of D.C.’s foster kids live in Maryland. Many of these children are being transported to their original D.C. school or to a Maryland school that they attended when they lived in a previous foster home. This trip can be as much as 40 miles for children in foster homes in the outer suburbs. Private transportation providers generally use a van transporting several children to and from different homes and schools, so many young people spend more than an hour in the van as they wait for others to be picked up or dropped off.

Children using private transportation are often unable to participate in extracurricular activities because transportation services rarely do pickups after 5 pm and often require that children be picked up at the same time every day. It is also difficult for foster children to visit friends (a big target of the normalcy law) because of distance and lack of public transportation.

Not only are long rides to school bad for kids, but they are also extremely expensive. Unfortunately, there is no data publicly available about how much governments are spending for school transportation. I know it was a major expense for the two private agencies for which I worked.

I also wonder if the benefit is worth the cost. The private agency I worked for most recently was paying a driver to pick up one of my clients and bring him to school daily. But my client was refusing to go to school about twice a week and was failing all his classes. I’m not sure this was a sensible investment.

There is only one way to meet the twin goals of normalcy and school stability. Rather than drive children all over the metropolitan area to get them to their original schools, we need to keep them close to home. This means trying to recruit more foster homes located in central cities.

The District of Columbia has launched a new recruiting campaign to do just that. But it is hard to believe this effort will succeed in the District and other cities where rapidly rising housing prices are driving away the people who are most likely to be foster parents. We may have to look at paying foster parents a salary or even providing them with housing in order to be able to keep our children where they belong: near their homes and schools.

This column was published in the Chronicle of Social Change on June 30, 2015.