The article entitled “Psychotropic Medication Patterns Among Youth in
Foster Care” (Pediatrics 2007;121:e157-e163) (1) addresses a very
important topic in the care of children and youth in foster care.
The article focuses on the high rate of concomitant psychotropic use among
children and youth in foster care in Texas who had been prescribed
psychotropic drugs, and found that, even though over 90% had these
medicines prescribed by a psychiatrist, the medication chosen seldom
“matched” the diagnosis. The article also summarized data indicating that
disparities in treatment exist, since Caucasian and Hispanic children were
more likely to have psychotropic medication use than African-American
children. What is missing from this article is the context in which
mental health care occurs for this population.
Children and youth enter foster care with a high incidence of genetic
or familial factors and a high burden of adverse childhood experiences
that predispose toward poor mental and emotional health outcomes (2).
Studies analyzing data from the National Survey of Child and Adolescent
Well-being (3,4,5)have indicated that 70% of children enter foster care
with a history of child abuse and/or neglect, over 40% are exposed to
active domestic violence at the time of child protective investigation,
and over 80% have a caregiver with significantly impaired parenting
skills. The same studies determined that the parents of these children
have high rates of mental illness, substance abuse and cognitive
impairment, all of which are likely to contribute to their impaired
parenting ability. These issues, in turn, raise the risk of emotional
health problems in their children, yielding rates of up to 80% at the time
of placement in foster care in some studies (2).
Removal from their family is emotionally traumatic for almost all
children. Foster care itself is characterized by transitions and
uncertainty. Children are placed with caregivers who are often strangers
to them, may experience multiple placements, and are faced with the
unknown of if or when they will return home. Birth parents may or may not
receive or take advantage of all the services they need to safely resume
the care of their children, or may not have a significant response to
treatment for mental health, drug addiction or other problems. Placement
with strangers, even very nice ones, is challenging for children and
teens. Ideally, visitation is an opportunity for parents and children to
maintain and improve their relationship with each other. However,
visitation may be unpredictable, chaotic or even harmful as children
attempt to manage their participation in two or more households. For
most children and youth in care, improving the health and functioning of
their biological parent would have a positive impact on their well-being.
In addition, recent research has demonstrated that assisting foster
parents in managing children’s mental health needs in their home improves
outcomes for children in foster care (6,7).
The current article, which summarizes an analysis of the Medicaid
claims data from one state during one month of one year, has some
shortcomings. The rates of developmental delays (7.6%) and child abuse
(5.1%) reported are so low compared with national statistics that it calls
into question the accuracy of other diagnostic information. This is
important because the authors note a large discrepancy between mental
health diagnosis and the psychopharmacological agents prescribed. This
discrepancy could result from mis-reporting of the treating diagnosis
and/or under-reporting of all the co-morbidities. This is further
compounded in younger children by the difficulty of making an accurate
mental health diagnosis since some symptoms may be the “common pathway”
for different diagnoses. For example, hyperactivity and inattention might
be ADHD, but could also represent oppositional defiant disorder, anxiety,
depression, or a learning disability, among other things. Sometimes, in
foster care, the diagnosis or diagnoses evolve as the provider becomes
familiar with the child over time. Other times, a child may respond to an
initial therapy and then have a series of crises that overwhelm their
ability to cope. For example, parents may visit erratically or suddenly
stop visiting, an expected reunification may fail to materialize, a parent
may enter drug rehabilitation or be incarcerated, or a foster parent may
become ill or choose to no longer care for the child. The diagnosis may
evolve but not necessarily be noted as the provider changes treatment in
response to the patient’s needs.
Psychotropic medication is but one modality of mental health
treatment, and the study failed to mention whether these children and
youth were also involved with other modalities. The study also is a point
prevalence study and does not indicate whether the children and youth had
been offered alternative medications that were found to be ineffective or
problematic before being placed on the medications in question. The study
also does not assess whether the medications were effective or not, or
whether their use was monitored appropriately or not. Psychotropic
medications that are used judiciously and monitored closely, in the
context of other modalities and a stable foster home, can have a very
positive impact on a child’s mental and emotional well-being.
Psychopharmacological medications are, in fact, sometimes used in
foster care for children and teens who are “out of control” and perceived
to be in “crisis”, especially if other interventions are not urgently
available. This is most likely to occur at entry to foster care or at
other crisis points. We know that sometimes youth in care ARE
inappropriately medicated, and we MUST avoid this. It happens when the
system fails. It happens when children are in a position where nobody
knows them or what is underlying their behavioral struggles—when they
don’t have anyone with a close enough relationship to ask the right
questions or hold them accountable or comfort them. It happens when they
don’t have the support they need to cope with events in their lives. Too
often, it is not the child who is disordered but it is the child’s life.
When we (the child welfare system and other professionals) don’t recognize
the places where we can intervene in the disordered life, we are stuck
with intervening only with the child. There is no medication that can
take away abuse or neglect. There is no medication that can serve as a
family. These are the facts of life for children and youth in foster
care and it is our job to help them to cope with their realities—and to
improve those realities whenever possible.
One very important question is whether children and teens may be
weaned off medications over time as more appropriate “contextual”
approaches are put into place. While some children and teens will
undoubtedly benefit from medications used to treat psychiatric illness
over the long term, others may benefit from interval treatment when they
are in crisis as long as other supports and interventions are also in
place and medications are used judiciously. At least two longitudinal
studies have demonstrated the positive impact of foster care. Fanshel and
Shinn showed in their 5 year longitudinal study that very high rates of
special education placement and academic under-achievement dropped
significantly over time in foster care (8). Another study by Horwitz and
Simms showed that rates of developmental delay dropped and overall “well-
being” improved for young children over 1 year in foster care(9).
In practice, there is a significant disconnect between what Medicaid
pays for regarding children in foster care and what the evidence suggests
is effective. For example, parent-child interactive therapy, trauma-
focused cognitive behavior therapy, therapeutic foster care as defined by
the Oregon Social Learning Center, and specialized training for the foster
parents of infants and pre-school children all have good evidence of
efficacy in this population (10, 11, 12, 13). However, neither Medicaid
nor child welfare have strategically re-directed the funds available for
mental health to provide incentives for the adoption of these modalities.
Medicaid does, however, fund psychotropic medication use.
There was at least one very positive finding in the current study.
Over 90% of children and youth in foster care who were on psychotropic
medication had received their prescriptions from a psychiatrist. The AAP
(14) and the Child Welfare League of America (15) have long recommended
that all children and youth entering foster care have access to mental
health evaluation. While the time frame is unclear, the data in this
study indicate that this population had significant access to mental
health care, for which child welfare should be congratulated in this
particular state.
In this study, the discrepancy between psychotropic medication
prescriptions for Caucasian or Hispanic children versus African-American
children suggests either that the latter have a lower burden of mental
health problems or, more likely, less access to needed services.
Unfortunately, most studies have shown that the latter is more often the
case (16).
The AAP recommends that medications, psychotropic and otherwise, be
studied more fully in children, so that we have a clearer understanding of
their benefits and risks (17). The data from this article support the
need for more thorough investigation of the use of psychotropic agents in
children and youth in foster care. However, children and youth in foster
care also need access to mental health evaluation by well-trained
pediatric mental health professionals, access to evidence-based mental
health interventions, well-trained and supported foster parents and
caseworkers, and access to a pediatric medical home. Medication is ONE of
the interventions we need to consider, but it should not be the first one
and it should never be the only one. A centralized Pediatric medical home
in our community is associated with improved mental health access, with
70% of children and youth in foster care having access to mental health
services (18). A medical home provides a level of oversight and
coordination for health care that is often lacking for children in foster
care. It should be noted that the state of Texas, where this study
originated, has developed stringent guidelines for the administration and
oversight of psychotropic medications in the foster care population.
However, timely access to specialized health and mental health services,
particularly for those children whose needs appear to exceed typical
“guidelines for care” is critical. The AAP and CWLA have long recommended
the development of centralized health and mental health administrative
structures within child welfare systems to support case workers and foster
parents, and to ensure that children in foster care receive appropriate
medical and mental health care and follow up services. Finally, birth
parents should also have access to evidence-based mental health services,
drug and alcohol rehabilitation services, and evidence-based parenting
interventions, because the well-being of the child and the possibility of
reunification with the biological family depends mostly on the improved
functioning of the parents.
References
1. Zito JM, Safer DJ, Devadatta S, Gardner JF, Thomas D, Coombes P,
Dubowski M, Mendez-Lewis M. Psychotropic medication patterns among youth
in foster care. Pediatrics. 2007;121:e157-e163
2. Simms M, Dubowitz H, Szilagyi MA. Health care needs of children
in the foster care system. Pediatrics. 2000;106:909-918.
3. Stahmer AC, Leslie LK, Hurlburt MS, Barth R, Webb MB, Landsverk
JA, Zhang J. Developmental and behavioral needs and service use for young
children in child welfare. Pediatrics. 2005;116:891-900.
4. Burns BJ, Phillips SD, Wagner HR, Barth R, Kolko DJ, Campbell Y,
Landsverk JA. Mental health need and access to mental health services by
youths involved with child welfare: A national survey. J Amer Acad of
Child Adolesc Psychol. 2004;43:960-970.
5. Leslie LK, Hurlburt MS, Landsverk JA, Barth RP, Slymen DJ.
Outpatient mental health services for children in foster care: A national
perspective. Child Abuse Negl. 2004;28:697-712.
6. Fisher PA, Gunnar MR, Dozier M, Bruce J, Pears KC. Effects of
therapeutic interventions for foster children on behavioral problems,
caregiver attachment, and stress regulatory neural systems.
7. Fisher PA, Burraston B, Pears K. The early intervention foster
care program: permanent placement outcomes from a randomized trial. Child
Maltr. 2005;10:61-71.
8. Fanshell, D., & Shinn, E. Children in Foster Care: A Longitudinal
Investigation. New York: Columbia University Press . 1978.
9. Horwitz SM, Balestracci KMB, Simms MD. Foster care placement improves
children’s functioning. Arch Pediatr Adolesc Med. 2001;155:1255-1261.
10. Stambaugh L, Burns BJ, Landsverk J, Reutz JR. Evidence-based
treatment for children in child welfare. Focal Point. 2007;21:12-15.
11. Marsenich L. Evidence-based practices in mental health services
for foster youth. California Institute for Mental Health. Sacramento, CA.
2002.
12. Dozier M. Developing evidence-based interventions for foster
children: An example of a randomized clinical trial with infants and
toddlers. J Soc Iss. 2006;62:767-786.
13. Landsverk JA, Burns BJ, Stambaugh LF, Reutz JAR. Mental health
care for children and adolescents in foster care: Review of the research
literature. Casey Family Programs. 2006.
14. American Academy of Pediatrics. Fostering health: Health care
standards for children and adolescents in foster care. Task Force on
Health Care for Children in Foster Care. District II, NY. 2005.
15. Child Welfare League of America. Standards of excellence for
health care services for children in out-of-home care. Washington, DC.
2007.
16. Garland AF, Hough RL, Landsverk JA, McCabe KM, Yeh M, Ganger WC,
Reynolds BJ. Racial and ethnic variations in mental health care
utilization among children in foster care. Children’s Services. 2000;3:133
-146.
17. Vitiello B. Psychopharmacology for young children: Clinical needs
and research opportunities. Pediatrics. 2001;108:983-989.
18. Jee SH, Szilagyi M, Blatt SD, Meguid V, Auinger P, Szilagyi PG.
Timely identification of mental health needs in two foster care medical
homes. Manuscript in process.
Conflict of Interest:
None declared
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