The San Jose Mercury News has begun publishing a multi-part series on the alarming use of psychotropic medications among youth in California’s foster-care system. Karen de Sá writes:
With alarming frequency, foster and health care providers are turning to a risky but convenient remedy to control the behavior of thousands of troubled kids: numbing them with psychiatric drugs that are untested on and often not approved for children.
An investigation by this newspaper found that nearly 1 out of every 4 adolescents in California’s foster care system is receiving these drugs — 3 times the rate for all adolescents nationwide. Over the last decade, almost 15 percent of the state’s foster children of all ages were prescribed the medications, known as psychotropics, part of a national treatment trend that is only beginning to receive broad scrutiny.
The first part of the series includes interviews with former foster children who’ve experienced long-term adverse effects after having been given psychotropic drugs while in foster care. It also presents some results of the Mercury News analysis of aggregate data on pharmacy benefit claims paid by the state’s Medicaid program for foster children (covering 2004-5 2013-14). The newspaper received the data months after de Sá filed a California Public Records Act request for 10 years of claims data; negotiations as to how much more data they might receive are ongoing.
Among the findings of the Mercury News analysis: Nearly 60% of California foster children were prescribed an antipsychotic, one of the psychotropic drugs of most concern.
Antipsychotics can have serious adverse effects such as rapid weight gain and diabetes. Often, foster children are given antipsychotics not because they have been diagnosed with schizophrenia or bipolar disorder, but because caregivers want to control children’s behavior. de Sá explains:
For children, the FDA has approved antipsychotics only to treat schizophrenia, bipolar disorder and severe autism — serious mental health conditions found in just 1 to 2 percent of the child population. But University of Maryland professor of pharmacy and psychiatry Julie Zito has found that the drugs often are prescribed off-label to control children’s behavior.
In a rare look at diagnoses of children covered by Medi-Cal, California’s public health system, Zito found that almost one-half of the antipsychotics used were off-label and about a third were for behavior problems such as ADHD, “conduct disorder” or “oppositional defiant disorder.” Her yet-to-be-published study found that in 2009 there was an 18-fold greater use of antipsychotics on foster children than on non-foster kids receiving Medi-Cal because of their families’ income levels. These findings were presented to the FDA in April.
All too often, foster children with behavioral issues risk losing their foster placements and ending up in a worse situation. It’s understandable why a physician considering such a scenario might prescribe an antipsychotic, with the goal of helping a child achieve a stable situation. But with too few providers who can offer foster children therapy to address their underlying mental-health needs, foster children often just keep taking the drugs — and if their situations get worse, the response is often to add another medication to the regimen. The Mercury News investigation found that “12.2 percent of California foster children who received a psych drug in 2013 were prescribed two, three, four or more psychotropic medications at a time — up from 10.1 percent in 2004.”
This is not the first investigation into the prescribing of antipsychotic drugs to foster children (or children in general). Most notably, a December 2011 report from the Government Accountability Office analyzed the patterns of psychotropic-drug prescribing to foster children in selected states (Florida, Maryland, Massachusetts, Michigan, Oregon, and Texas). The GAO found prescriptions of psychotropic drugs for children under one year old, as well as hundreds of children prescribed five or more psychotropic drugs simultaneously. Since then several states, including California, have adopted policies that give extra scrutiny to the prescription of antipsychotics to children with Medicaid coverage, or to the subset of Medicaid beneficiaries who are also in the foster-care system.
Recent progress is worth noting, but de Sá and her colleagues demonstrate how far we still have to go to assure that foster children get appropriate care for their mental-health needs, rather than being doped with cocktails of drugs that leave them sedated but at high risk of health problems. I look forward to reading the rest of the Mercury-News series as it is published, and hope it will give us a glimpse of what a better system might look like and how we can achieve it.