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.