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Monday, December 26, 2011

Foster Children and Psychotropic Medications

There have been several high profile media reports on the high use of psychotropic drugs being used with foster children.  Thus, a study by the Government Accountability Office (GAO), an office of the United States government, has provided a useful look at the practices in 5 US states. As seen in the media reports, they find that foster children are indeed prescribed drugs at rates significantly in excess of non-foster children. They have not succumbed to hyperbolae however and note that children in foster care can also present with much higher mental health issues. Yet, they also challenge the practices that they have found, particularly when children are being prescribed high doses or high numbers of drugs.

One crucial issue that has often been missed in the debate is that the problem is not restricted to foster children. As they state:

According  to   our  experts,  no  evidence  supports  the  concomitant  use  of  five  or  more   psychotropic  drugs  in  adults  or  children,  yet  hundreds  of  both  foster  and   nonfoster  children  were  prescribed  such  a  medication  regimen.  Similarly,   thousands  of  foster  and  nonfoster  children  were  prescribed  doses   exceeding  maximum  levels  cited  in  guidelines  based  on  FDA-­approved   drug  labels,  which  our  experts  said  increases  the  potential  for  adverse   side  effects,  and  does  not  typically  increase  the  efficacy  of  the  drugs  to   any  significant  extent.14  Further,  foster  and  nonfoster  children  under  1   year  old  were  prescribed  psychotropic  drugs,  which  our  experts  said  have   no  established  use  for  mental  health  conditions  in  infants  and  could  result   in  serious  adverse  effects. (p.7)

In other words, there are significant reasons to be concerned about the ways in which these medications are being used with children in general. There is no doubt, however, that the foster child population is receiving these medications at a much higher rate. When asking why, the GAO notes:

These  factors  included  the  greater  exposure  to  trauma  before  entering   state  care,  frequent  changes  in  foster  placements,  and  varying  state   oversight  policies.  However,  our  literature  search  identified  a  relatively   small  number  of  studies  that  have  been  conducted  to  determine  to  what   extent  each  of  these  factors  contributes  to  higher  prescription  rates,  or   whether  additional  factors  are  involved. (p.10)

One of the more concerning aspects is that medication is being prescribed because child protection has apparently not found ways to sustain stable foster care placements. Unlike issues such as pre-foster care trauma, placement is an issue which might often be better managed. Multiple changes in where children live, lead to greater emotional angst, re-occuring abandonment and loss and an inability for symptoms arising from trauma to settle. Rather than treat with medications, other solutions might be appropriate that would include greater emphasis on placement stability, better efforts to sustain children within family systems and faster decisions for permanency for children (be that back to family, kinship care or other long term placements such as adoption). Placement instability may be one of the most damaging experiences for children. If you have no regular place to call home, then you also have no persistent safe haven possible.

The American Academy of Child and Adolescent Psychiatrists (AACAP) recommends that there be a clear consent process for children in foster care that includes clarity on who can consent to treatment and that this be based on a clear understanding of diagnosis and what, why and how medications are being used. They also recommend that child protection have a consultation process so that cases are carefully managed and monitored.

This report raises some thoughtful ways through which good case management can occur emphasizing that those who manage these issues be well informed about what is happening with each case and why. They also recommend that child protection and caregivers be kept informed about what medications are being used and the positive and negative implications.


Dr. Peter Breggin, a noted psychiatrist and commentator on psychiatric medications has written an op-ed piece that also considers the GAO report.

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