pro's and con's of medicating foster care youth, legislation regarding mediating foster care youth

1. Running head: PSYCHOTROPIC MEDICATION USE 1
Psychotropic Medication Use in Foster Youth within the United States
Alexandra V. Bembanaste & Elizabeth Wolf
Florida International University
04/17/2018

2. PSYCHOTROPIC MEDICATION USE 2
Summary
About one half to three quarters of children and youth entering foster care in the United
States exhibit symptoms that warrant mental health care (Lansverk, Burns, Stambaugh, & Reutz,
2009). Commonly used effective treatments for both adults and adolescents experiencing mental
health symptoms are psychosocial interventions, case management services, individual or group
counseling, and at times, use of psychotropic medication. When appropriate services are not
available or accessible, in a timely manner, psychotropic medication is often prescribed (Alavi &
Calleja, 2012; Lohr & Jones, 2016).
Current context
Research shows that in the United States over the past two decades, the use of
psychotropic medication for children and adolescents has risen, especially in foster care youth
(Narendorf, Bertram, & McMillen, 2011). This is evident as seen in the high rate of “13% to
37% of foster care youth on psychotropic medications compared to the 4% of youth in the
general population” (Alavi & Calleja, 2012, p.2). The former director of the National Institute of
Mental Health referenced a “five-fold increase in the number of children under 18 on psycho-
stimulants from 1988-1994 to 2007–2010, with the most recent rate of 4.2 percent” in 2014
(Insel, 2014, para. 2). The recent increase in psychotropic medication use can be linked to new
pharmaceutical marketing strategies, barriers to accessing services, and insurance coverage
issues (Magellan Health, 2017). Considering the fast-acting nature of these medications, the
accompanying side effects can be serious. Consequently, conducting a thorough assessment of
the benefits and risks is needed before administering or acquiring court authorization to
administer to children and adolescents. Recently, there has been concern from supporters and
opponents of medication administration to youth concerning the proper oversight and monitoring
when using psychotropic medications (GAO, 2011).

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Factors that leave this population at an increased risk for medication error are prevalent
off-label use, frequent movement of placements, and involvement with multiple-organizations
and systems (U.S. Government Accountability Office [GAO], 2011). In order to tackle these
factors, a multidisciplinary team approach must be taken and psychosocial treatment must
accompany psychotropic medication use to achieve the best outcomes (Houshyar, 2014; Crimson
& Argo, 2009; Alavi & Calleja, 2012). Some evidence-based psychosocial/therapeutic
interventions that have been cited to be effective with this population are “Multi-systemic
Therapy (MST), Functional Family Therapy (FFT), and Trauma-Focused Cognitive Behavioral
Therapy (CBT)” (Houshyar, 2014, p. 8).
Psychotropic medication use
Due to the complexity of experiences and trauma experienced by this population,
children/youth in care often present with indicators of more than one mental disorder (Crimson
& Argo, 2009; GAO, 2011; Magellan Health, 2017). Alavi & Calleja, (2012) found that about
“80% of all youth involved in the child welfare system have emotional and behavioral problems,
developmental delays, and other conditions requiring mental health services” (p.78). Factors
such as availability and limited resources may affect access to these services and sometimes
children may not be able to access them at all. Scozzaro & Janikowski (2015) found that only
half of foster care youth receive the proper psychosocial/therapeutic interventions that should
accompany the use of these medications.
Therefore, psychotropic medication often becomes the first and only line of treatment
when psychosocial interventions are not available as seen by the high rates of polypharmacy and
psychotropic medication use. For example, “a 2.5- to eightfold increase in the rate of
polypharmacy” and “13.5% of children and adolescents in foster care are prescribed

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psychotropic medications” (Naylor et al., 2007, p. 175). Due to this high prevalence rate, all
child welfare professionals and stakeholders must be aware of the pros and cons concerning their
administration and use, as well as the protocols to be followed if deemed ‘medically necessary’
by a medical professional.
Child welfare and medical professionals have found medications such as stimulants,
psychotropics, and mood stabilizers to be effective chemical treatments for children and youth in
foster care. Prevalent disorders and issues amongst this population that warrant medications
include ADHD, anxiety-related disorders, bipolar disorder, depression, mood instability, and
aggression (Crimson & Argo, 2009; Solchany, 2011;Lohr & Jones,2016).
Although there are a variety of environmental and psychosocial factors that contribute to
these issues/disorders, medication is often favorable because it can target the biological nature of
some mental disorders. For example, Landsverk et al. (2009) notes that stimulants have positive
effects in treating comorbid issues in children with Attention Deficit Hyperactivity Disorder
(ADHD) and is cited as one of the “most effective treatments for ADHD in psychiatry” (Crimson
& Argo, 2009, p.3). Another class of drugs that has been widely used and effective in adults and
children in treating anxiety-related disorders and depression is Selective Serotonin Reuptake
Inhibitors (SSRI). Specifically, fluoxetine (a SSRI) is often used as it is the only Food and Drug
Administration-approved medication for use in children and adolescents with depression.
Lithium, a mood stabilizer, has been effective in treating mood instability and Risperidone, a
medication for treating aggression in youth ,are other popular psychotropic medications
commonly used in this population (Crimson & Argo,2009; Lohr & Jones, 2016). Similarly,
another antipsychotic that is heavily used with adults and children is Risperdal as it has been
“effective in reducing disruptive behaviors” (Crimson & Argo, 2009, p.3).

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In Florida, “foster children were prescribed psychotropic drugs at rates 2.7 to 4.5 times
higher than were non-foster children in Medicaid in 2008” (GAO, 2011, p. 16). To address the
concern raised by the American Academy of Child & Adolescent Psychiatry (AACAP) about the
high rate of psychotropic use in Florida, state officials suggest that this higher incidence is due to
the higher prevalence rate of mental health issues in this population compared to non-foster
children (GAO, 2011).
Due to the medication’s potential effectiveness and higher prevalence of trauma
experienced by those in foster care, children and youth are often prescribed antipsychotic
medications that have not been fully studied for use with this age group. For example,
“thousands of foster children were prescribed doses exceeding maximum levels cited in
guidelines based on information in FDA -approved drug labels” (GAO, 2011, p.7). Among
supporters and opponents, this prescribing practice is their biggest concern. Although, many
clinical trials have been conducted on the effectiveness of antipsychotic medications in adults,
this is not the case for children and adolescents. Due to the vulnerable nature of youth, many
pharmaceuticals companies shy away from conducting trials on psychotropic medications with
this population. For example, “before the FDA initiated a pediatric program in 1998, only about
20 percent of drugs approved by the FDA were labeled for pediatric use” (FDA, 2016, para.2).
More recently, the “FDA has approved only 31% of psychotropic medications for use in
children or adolescents. However, it is estimated that currently more than 75% of the
prescriptions written for psychiatric illness in this population is off-label in usage” (Solchany,
2011, p. 17).
Therefore, as their symptomatology worsens, doctors are left by necessity to prescribe
off-label use; estimating dosage by a child's size, weight, and what has worked in the past for

6. PSYCHOTROPIC MEDICATION USE 6
other adults with similar symptoms. Because this occurs, professionals cite the importance of
using a combination of appropriate monitoring techniques and accompanying psychosocial
interventions (Alavi & Calleja, 2012; Lohr & Jones, 2016; Solchany, 2011).
Additionally, there has been concern that some data may suggest increasing number of
youth receiving medications without concurrent mental health services (Alavi & Calleja, 2012;
Lohr & Jones, 2016; Houshyar, 2014). The Centers for Medicaid and Medicare Services (CMS),
make note that the higher rates of psychotropic use may be due to the lack of timely access to
effective behavioral health care, as well as fewer evidence-based psychosocial interventions for
children/youth than for adults. Therefore, both supporters and opponents advocate for protocols
that must be followed when a child is on these medications.
Efforts being made
Houshyar (2014) “reported that 26 states had written policy/guideline on psychotropic
medication use; 13 states were in the process of developing a policy/ guideline; and 9 states had
no policy/ guideline on psychotropic medication use” (p.6). Along with developing
policies/guidelines, some states such as Texas, North Carolina, & Rhode Island have
implemented innovative performance improvement measures such as health program services
that directly engage all stakeholders of this issue in efforts to address concerns regarding
psychotropic medication use in foster care youth. For example, Texas has instituted a program
that benefits foster care youth by establishing the STAR Health Program. According to Houshyar
(2014), “the STAR health program serves 30,000 children and youth in foster care and
administers the electronic Health Passport, which is largely populated by Medicaid claims and
pharmacy data, with more limited input by providers” (p.6). After program implementation,
Texas has seen increases in health wellness visits and decreases in psychiatric admissions,

7. PSYCHOTROPIC MEDICATION USE 7
psychotropic medication use, and polypharmacy prevalence amongst this population. A North
Carolina, also, developed a pilot program called A+KIDS aimed at children 18 and under on
Medicaid, including those in foster care. This initiative requires physicians “prescribing
medication to children on Medicaid to use a web-based application that ensures physicians have
information on psychotropics, side effects, and possible alternatives before writing a
prescription” (Houshyar, 2014, p. 6). Rhode Island has made changes in their prescribing
practices by enlisting “psychiatrists to oversee the prescribing of psychotropic medications for
foster care youth and requires administrators to get consent from the consulting psychiatrist for
new prescriptions, as well as, flag new medication requests and obtain the consulting
psychiatrist’s authorization” (Houshyar, 2014, p.7).
Although advances have been made in changing prescribing practices, efforts to
safeguard this population are still being made. Policy makers, general public, and related
organizations (such as the AACAP and CMS) still raise concern about the limited “use of
evidence-based therapies, appropriateness of medication dosage that are often not fully supported
by documentation, concurrent use of these medications, and the use of psychotropics in infants”
(p.7).
Legislation
The administration of these medications to children and youth has brought much pressure
to policymakers to establish protocols to safeguard this population. Previous laws and policies
that have addressed psychotropic medication use and contributed to the current administrative
code in Florida are the Child & Family Services Improvement Act of 2006, Fostering
Connections to Success & Increasing Adoptions Act of 2008, and Child & Family Services
Improvement & Innovation Act of 2011.

8. PSYCHOTROPIC MEDICATION USE 8
Child & Family Services Improvement Act of 2006 ensures that medically-related
professionals are both “consulted and involved” in the assessment of well-being for the child and
his/her treatment plan (Child & Family Services Improvement Act, 2006). Fostering Connections
to Success & Increasing Adoptions Act of 2008 “requires the state to develop a plan for ongoing
oversight and coordination of health care services for any child in foster care placement”
(Fostering Connections to Success & Increasing Adoptions Act, 2008, p. 13). This addresses a
main component of the use of psychotropics with this population because continual oversight
and monitoring of the side effects and its actual effectiveness in reducing symptoms is key for
the appropriate treatment of the child. Child & Family Services Improvement & Innovation Act
of 2011 requires that states plan for “oversight and coordination of healthcare services for any
child in foster care placement to include an outline of monitoring and treatment of emotional
trauma associated with child maltreatment and removal from home and to protocols for
appropriate use in monitoring of psychotropic medications” (Child & Family Services
Improvement & Innovation Act, 2011, p.1).
Although states differ in their protocols for authorizing administration of psychotropic
medication, Florida requires biological parent consent. In the case that parental consent cannot
be obtained or is denied, court approval is pursued if deemed medically
necessary. “Unfortunately, states still report many cases where children in foster care were given
psychotropic drugs without the required legal consent. Child advocates and clinicians see this as
an area that needs to be rectified given the importance of the decision to use psychotropic agents
in children” (Magellan Health, 2017, p.8).
The Florida Administrative Code Chapter Title: Psychotropic Medication for Children in
Out of Home Care 65C-35.007: Authority to provide psychotropic medication to children in out

9. PSYCHOTROPIC MEDICATION USE 9
of home care states that when a child is placed in out of home care, the “parents or legal
guardians retain the right to consent or decline the administration of psychotropic medications
for the child taken into state care”. If parental rights are still intact, parents or guardians may
decline to approve the administration of psychotropic medications or withdraw consent.
However, “if any party related to the dependency action believes that the medication is in the
best interest of the child and medically necessary”, the case manager must follow a series of
steps for the court to override this decision.
The case manager must contact the prescribing practitioner within one business day of
being notified. The prescribing practitioner then determines whether the medication is medically
necessary for the child despite the lack of authorization from parents or legal guardian(s). A
Medical Report must be completed by the prescribing practitioner and provided to Children’s
Legal Services within three days in order to file a motion seeking court authorization for the
administration of psychotropic medication (Fla. Admin. Code R. 65C-35.007).
Our proposal
Currently in Florida, it is required that all children in state custody have their dependency
cases reviewed periodically to assess efforts made towards permanency and review of their
treatment/case plan. Citizen review panels (CRP) are comprised of educated citizen volunteers
that utilize a form of performance improvement measures by examining the mechanisms of the
child welfare system and “making suggestions for improvement” by examining randomly chosen
cases and creating reports on findings (Jones, 2004, p. 1118). Because this population is so
vulnerable, all necessary safeguards and review measures must be taken to ensure the
appropriateness of all aspects of their care, especially when powerful psychotropic medications
are being administered.

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The Child Welfare Institute published a review series on foster care review boards/panels
and found that review boards/panels further support accountability and improve outcomes by
examining all efforts being made to help the child in question (“Strategic Planning for Effective
Foster Care Review”, 2002). Review panels “often provide the only opportunity to monitor
critical case activities and how law and policy are implemented” “Strategic Planning for
Effective Foster Care Review”, 2002, p.17). A study conducted by Jones (2004) shows that
review panels/boards have been effective in increasing communication between child welfare
professionals and sheds light on roles and limitations of those involved. An effective review
panel that consists of child-welfare related professionals would be able to examine if there were
any instances that psychotropic medications were inappropriately administered, either due to
dosage errors or diagnosis errors.
Our proposal is to implement a medically-based review panel that would comprise of a
psychiatrist, two psychiatric nurses, a Guardian Ad Litem, a child welfare attorney, and Licensed
Clinical Social Worker. These professionals were selected because of their exposure and
expertise regarding child-welfare. The review panel will meet monthly and conduct an in-depth
review on 10 randomly chosen child welfare cases that pursued court authorization for
psychotropic medication. The panel will gather all related information and records regarding the
child’s family, psychiatric, social, and medical history in order to fully assess the dependent
child’s case in order to maintain accountability of all parties involved, evaluate all medications
and treatment, and track progress towards outcomes.
We suggested this review panel because it provides multiple perspectives from
professionals regarding many aspects of the child’s case plan. Also, unlike the prescribing
practitioner that advises the court regarding psychotropic medication for the child, the review

11. PSYCHOTROPIC MEDICATION USE 11
panel will have sufficient time and available resources to review all details of the case, especially
in those cases that biological parents or legal guardian(s) declined to consent for psychotropic
medication. Also, members of the panel can assist in identifying and suggesting proper
monitoring and oversight techniques if improvement is needed in this area. Much like the CRP’s,
our medical review panel will adopt a multidisciplinary team approach to review medications,
psychosocial treatments, steps to permanency, and other components of the child’s case plan.
In conclusion, the use of psychotropic medication to address signs and symptoms of
mental health in foster children warrants special precautions due to the powerful nature of these
drugs. Proper oversight and monitoring is needed due to procedures such as off-label use and
unavailability of complimentary therapeutic interventions in order to ensure better outcomes for
this vulnerable population.

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