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Think Tank

How To Deal With Drug Problems in State’s Foster Care Program

Recent reports shed light on troubling practices in California’s foster care system.

An investigation and series of articles published this fall by the San Jose Mercury News and Bay Area News Group showed that pharmaceutical companies are spending millions of dollars to influence physicians who prescribe psychiatric medications to California children in foster care. The investigation found that children in the state foster care system are prescribed psychiatric drugs at a rate three times higher than children nationwide.

Legislators and state health leaders acknowledged the situation and said it is part of larger systemic problems facing the state’s foster care program.

Mercury News editorial this fall called for swift action.

We asked physicians, lawmakers, state health officials and consumer advocates how California should deal with the situation.

We got responses from:

Expert Panel Is Working on Recommendations

The dialog over foster youth and the use of psychotropic medication runs deep with emotion and history. In an effort to understand where California is going, you must understand where we have been in our journey to improve the lives of children entrusted in the care of the state.

In 1999, California took a step forward as the first state to require judicial approval for the prescription of psychotropic medications for foster youth. That policy is still in place today; however the state, counties, child advocates and other stakeholders all agree that system needs improvement, and inclusive policy development practices are currently moving forward.

Last year, under the leadership of the California Department of Social Services and the California Department of Health Care Services, an expert panel was convened to provide advice and guidance regarding the development of a state protocol that includes standards to improve the oversight and monitoring of psychotropic medication use in children and youth in foster care. The expert panel includes physical, mental and behavioral health experts, current and former foster youth and child advocates.

The work being accomplished is thoughtful and intended to allow for independence in treatment or care while at the same time providing medication information, training and educational resources to foster care children and youth, parents, families, caregivers, pharmacists, providers and social workers. The identification of common data elements and agreements to share individual information will provide county social workers and other decision makers with client-level reports not previously available.

Additionally, the refinement of best practices will recognize that psychotropic medications are one element in a comprehensive treatment that must include other psychosocial and environmental interventions and monitoring parameters which mitigate potentially serious adverse effects of these drugs.

Once the panel’s recommendations are complete, additional support for this project will be needed to define legal standards which ensure youth being prescribed psychotropic medications receive the minimum number of prescriptions necessary in the lowest therapeutic doses for the appropriate age.

Lastly, we must resist any distractions that do not positively contribute to the success of this effort. There will be much more benefit to the foster children and youth who require this level of care when a solution is implemented that pushes aside agendas and focuses on what really matters, the development of explicit policies and practices that minimize incidences of overuse, underuse or the inappropriate use of psychotropic medications.

Foster Kids Need Compassion, Not Drugs

Articles in the San Jose Mercury News and Bay Area News Group show that pharmaceutical companies are pushing doctors to prescribe psychiatric mediations for children in foster care. I have worked in the foster care industry for 28 years and this is no surprise to me.

Children who come into the foster care system are traumatized, both by the molestation, abuse and/or neglect they have suffered, as well as by losing their family and other personal connections by being removed into the foster care system. Research clearly shows that children who have been traumatized in these ways have a far higher baseline level of stress hormones (making it harder for them to deal with the challenges of life), developmentally function at half their chronological age and have developed coping mechanisms that can present as bizarre and inappropriate in a “normal” family.

For decades, a primary target of the foster care system has been the behavioral management of the children. With that being the primary goal, the laziest solution is to control the children’s maladaptive behaviors by drugging them. The trouble is, this is mere symptom reduction and does not deal with the core issue of a child having been traumatized and continually feeling at risk. Without treatment of the root causes, a foster child will go into adulthood without ever having received true help, just a band-aid to make them more manageable.

In my opinion, what is needed is not more medication, but for the foster system to shift the focus from behavioral management to providing compassionate care with training and insight into the trauma these children have experienced and how it influences their behaviors. There are parenting methods such as Common Sense Parenting, Love and Logic, and especially Trust Based Parenting Intervention that give foster parents the tools to understand why the children act the way they do. By using understanding and compassion, these methods train foster parents how to work with the children to reduce their level of stress and give them coping mechanisms that will serve them for life, not just until the prescription runs out. Foster care must be more than housing and behavioral management. It must recruit and train the most caring of people to love children, understand why their maladaptive behaviors exist, work patiently with them to help them feel safe and teach them coping skills that will last a lifetime.

Publish Data Quarterly, Make Physician Lists

Here are some policy suggestions to stem the tide of psychotropic drug prescriptions to children in foster care:

1. The Department of Social Services should publish every quarter the percentage of children in foster care and other residential settings under state care who receive one or more prescriptions for psychotropic drugs. This publicly funded aggregated data has obvious public health relevance and no confidentiality concerns exist.

2. Any payment to a physician from a drug company is a payment for good services rendered (i.e., increasing a company’s revenues by enticing physicians to write prescriptions to foster children publicly reimbursed through Medicaid). Consumer bureaus should develop lists of physicians who do not accept funding of any kind from pharmaceutical companies. The medical licensing board should require physicians to display prominent signs in their waiting rooms informing patients about their drug industry funding.

 3. Alaska attorney Jim Gottstein has argued that cocktails of antipsychotics for behavior problems of children are prescriptions for non-medically indicated reasons and thus constitute false claims for Medicaid reimbursement according its own rules. If so, California Medi-Cal might just wish to obey federal law: screen those prescriptions properly and refuse to reimburse them (and kindly notify prescribers that they are breaking the law).

4. The executives of pharmaceutical companies found to have engaged in illegal marketing of their products should be held criminally responsible rather than their companies just paying fines as the cost of doing business (like $10.4 billion in 74 court judgments and settlements between 2010 and 2012).

5. Child welfare workers and juvenile court judges have an ethical duty to inform themselves responsibly about the drugs they encourage and sometimes compel non-consenting children to take. The drug industry floods the market with studies purporting to show short-term improvement in symptoms while it studiously under-documents harms and long-term consequences. Perhaps these officials should be held responsible when things go wrong, not just given a free pass because they don’t prescribe.

6. A stable foster placement matters for a child’s well-being, thus child welfare workers may understandably refer a child for a medication evaluation in order to avoid interrupting the placement. But psychological and behavioral instabilities shown by maltreated or neglected children are normal reactions to adversity, not mental illnesses to medicalize. A severe or delayed reaction to maltreatment does not automatically justify a prescription; it requires even more personal, individual attention given to a child.

Medical Board 'Thoroughly Committed' To Addressing Issue

The Medical Board of California takes the issue of inappropriate prescribing very seriously. The board is committed to consumer protection, and enforces this commitment through the education and oversight of its physicians. The board is currently working with the California Department of Health Care Services and the California Department of Social Services to identify physicians who may be inappropriately prescribing medications to foster children.

It is very important, for this issue and other cross-cutting issues, that state agencies collaborate and work together to share information that will allow each agency to take the necessary actions against their licensees. In addition, working together on a “united front” to tackle such an issue can provide more comprehensive solutions in order to continue to protect California consumers.

The board encourages any individual, agency, media or court official to notify the board and file a complaint if they believe a physician may be inappropriately prescribing. The board needs to be notified in order to investigate and take appropriate action against a physician’s license who is found to be inappropriately prescribing medications. It is critical for the board to be involved in this issue, as the board is the only state agency that can take the appropriate action against a physician’s license and his/her ability to practice.

The board is thoroughly committed to addressing the inappropriate prescribing issue by taking the appropriate action when necessary and providing and disseminating education to physicians, consumers and other state agencies.

California Must Do More To Protect Foster Children

The investigation by the Bay Area News Group found that from 2010 to 2013 pharmaceutical drugmakers spent more than $14 million on doctors who prescribe drugs to children in our foster care system. Payments to doctors for prescribing certain drugs exert undue influence, interfere with the doctor-patient relationship and induce physicians to breach their duty of care to their patients.

We’ve seen similar conflicts play out within our University of California hospitals. Robert Pedowitz, then-chair of the UCLA orthopedics department, reported widespread financial conflicts of interest involving physician payments by device manufacturers that may have compromised patient care. Instead of investigating, UCLA demoted Pedowitz. UCLA eventually paid a $10 million settlement but admitted no wrongdoing and never addressed the underlying conflicts of interest. Neither the UC system nor the foster system have a policy to disclose and address manufacturer payments to doctors. At a minimum, all physicians should be required to disclose these financial ties to their patients before prescribing.

This investigation comes just months after the Orange County and Santa Clara district attorneys filed lawsuits against five of the world’s largest pharmaceutical drugmakers alleging a “culture of deception” that was designed to boost sales of dangerous narcotics. CDC has said that overprescribing leads to prescription drug overdose deaths — 22,114 deaths were recorded in 2012. Problem prescribing to foster youth is another symptom of this national patient safety and overprescribing crisis.

In August, then-state Sen. Ted Lieu (D-Torrance) asked the California Medical Board to investigate doctors who prescribed dangerous psychotropic medications to children that were not approved for children, without reviewing medical records or drug history. After these latest “pay for play” revelations, the Medical Board agreed to Consumer Watchdog’s call to include financial conflicts of interest in their investigation. The Medical Board must determine if foster children are being inappropriately prescribed psychiatric drugs because of drug manufacturer payments to physicians, and if so, hold those physicians accountable.

California has the nation’s largest foster care system, which houses, feeds and is supposed to protect the most vulnerable children in our society. The courts and foster parents defer almost entirely to the judgment of medical professionals. This reliance and level of trust is extraordinary and makes this issue one of special concern. California foster children are prescribed astonishing amounts of prescription drugs — in both quantity and dosage — at a level higher than any other demographic group aside from those in hospice care. We must do more to protect them.