Weekly Column

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Jan 06 2012

“The Troubling Cost of Medicating America’s Foster Children”

Weekly Column By Senator Susan Collins

More than half a million children are in foster care in the United States, including 1,400 here in Maine. Typically, these children have been placed in care because they have been abused or neglected by their parents. Children in foster care also tend to have more serious mental, emotional or behavioral disorders than other children. As a consequence, many are exceedingly vulnerable.

I am troubled by recent national news reports that the use of powerful psychotropic drugs to treat depression, anxiety, and other mental-health disorders is particularly high for children in foster care. While some children with behavioral and mental disorders may benefit from these drugs, children in foster care are at particular risk of receiving too many or inappropriate medications. They often experience frequent changes in their foster placements and, as a result, are less likely to receive the careful medical and psychological oversight that would normally be exercised by a parent. Some state welfare agencies appear to do little to monitor the use of these medications.

That is why I joined my Senate colleagues in requesting the Government Accountability Office (GAO) to compare the rates of psychotropic prescriptions for foster and non-foster children on Medicaid. We also asked the GAO to review state efforts to monitor the prescription of these powerful medications for children in foster care.

According to the GAO, foster children in the five states examined for the report (Florida, Massachusetts, Michigan, Oregon, and Texas) were prescribed psychotropic drugs at two to more than four times the rate that these drugs were prescribed to non-foster children participating in Medicaid.

While these higher rates do not necessarily mean that the drugs were prescribed inappropriately given the serious problems of some foster children, I am alarmed by the GAO finding that, in hundreds of cases, five or more psychotropic drugs were prescribed concurrently. Moreover, in thousands of cases, the prescribed doses exceeded maximum guidelines. Of greatest concern was the finding that these powerful drugs were prescribed to thousands of infants. Given the possibility for serious adverse side effects, I find it hard to imagine any scenario that would justify the prescription of five or more of these powerful drugs to a child. I find it impossible to imagine that it would ever be appropriate to prescribe them for an infant. The scientific literature supports this skepticism.

Last month, I participated in a Senate hearing that coincided with the release of the GAO report. We heard from many expert witnesses, but the most powerful testimony of the day came from a 12-year-old boy from Texas.

He had been in foster care since the age of six, in a succession of three homes. By the time he was adopted two years ago, he had been on 20 different psychotropic drugs - sometimes five at a time. He was constantly distracted, dazed, irritable, and often in trouble at school.

His adoptive parents wanted him to live a normal life without so many drugs in his system. Now, instead of taking powerful drugs, he is getting counseling and has the support of loving parents. He is an honors student, plays first-chair clarinet, runs cross-country, and recently took part in a school play. The inspiring story of this boy and his adoptive parents demonstrates that these drugs, if not used carefully, can create problems rather than solve them.

Earlier this year, Congress passed legislation to require states to establish protocols for the prescription of psychotropic drugs to children in foster care as a condition of eligibility for federal child welfare funds. The new law, however, does not specify what those protocols should be. As a consequence, there is tremendous variation from state to state, and none of the states examined by the GAO met standards established by the American Association of Child and Adolescent Psychiatry. Clearly, states need to do more to strengthen the oversight of the care provided to children in foster care.

The State of Maine became aware of this problem some time ago and has taken positive steps to address this issue. A 16-state study that evaluated Medicaid data from 2004 to 2007 found that 20 percent of Maine foster children were on antipsychotics, four times the rate of non-foster children. Following that study, Maine formed a multidisciplinary work group in 2009 that brought together the foster-care community, primary care practitioners, and child welfare authorities to develop a procedure for ensuring that antipsychotics were prescribed only when appropriate. As a result of this informed approach, Maine now is among the top half of states on all quality measures of appropriate antipsychotic use among these children, and prescription rates here are declining, even as they rise in other states.

We have a fundamental responsibility to provide for the health and well being of these vulnerable children. We provide funding for their medical care, for the foster systems that support them, and for the schools they attend. Our responsibility does not, however, end with writing a check. Ensuring that they are not inundated with unnecessary medications and have the support of loving foster or adoptive parents must be our goal.