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One Step Forward, One Step Back in Medication Reform for Foster Children

Children in California’s foster care system are prescribed psychotropic medication at a much higher rate than other children in California and more than three times the national average, according to an investigative report by the Bay Area News Group.

Advocates say foster children also receive multiple kinds of psychotropic medications — including antidepressants, mood stabilizers, stimulants and antipsychotic drugs — at high doses and at young ages.

Roughly one-fourth of children in California foster care were prescribed psychotropic medication, including some medicines that weren’t approved by FDA for use in children, the report said. In some cases, children received four medications at a time.

An oversight hearing in the California Legislature this month examined the state’s progress in what is now a decade-long attempt to reform the rules around prescribing for foster kids.

“We continue to hear regularly … that children are not routinely being provided the effective mental health services they need,” said state Sen. Mike McGuire (D-Healdsburg), co-chair of the joint committee hearing by the Senate Committee on Health and the Senate Committee on Human Services.

Four bills in the Legislature seek to change the way psychotropic drugs are administered to foster youth:

  • SB 238, by state Sens. Holly Mitchell (D-Los Angeles) and Jim Beall (D-San Jose), would require the state to provide more data on the number of children in foster care who are prescribed psychotropic drugs, along with other medications that might cause harmful interactions;
  • SB 253, by state Sen. Bill Monning (D-Carmel), would change juvenile courts’ process for authorizing psychotropic drugs by prohibiting such drugs from being authorized without prior medical examination and ongoing monitoring of the child;
  • SB 319, by Beall, would establish a system for public health nurses to monitor and oversee anyone in foster care who is prescribed psychotropic medications; and
  • SB 484, by Beall, would establish treatment protocols and state oversight of psychotropic drugs in group-home settings.

New Prescribing Guidelines Released

California health officials this month released a set of guidelines for providers to try to limit overprescribing.

The guidelines are designed to get providers to start children on a lower scale of treatment, with non-drug therapies rather than psychotropics. It also calls for doctors to use medicines approved for use in children by FDA and asks them to cut down on medication doses and eventually wean children off of those medications.

For many people who have been advocating for major reform to substantively change the way psychotropic medications are prescribed to foster kids in California, though, the incremental progress made so far has been troubling.  

“While it’s disturbing to hear about these serious problems, it’s frankly more disturbing that conversations with the Department of Health Care Services indicate they have no information about kids systematically failing to receive needed services,” McGuire said.

“If we don’t know about the problem, I would suggest it’s because the state’s grievance and oversight process has failed,” McGuire said. “And if we don’t know about the problem and don’t measure it, then we can’t fix it.”

Guidelines actually are a big step, according to Karen Baylor, deputy director of mental health and substance use disorder services at DHCS, which helped develop the guidelines.

“We want to know how counties are monitoring the safety and effectiveness of medication practices,” Baylor said. “We want to make sure all the counties have policies and procedures in place regarding monitoring medications for psychotropic use. Are they seeing any quality-of-care concerns? And how are they addressing those quality-of-care concerns at the local level?”

Advocates Call for Mandatory Monitoring

To Anna Johnson, policy analyst for the National Center for Youth Law, the solution to this problem needs to be implemented on a bigger scale.

“Our current system is far from the ideal,” Johnson said. “But the barrier is not in the funding, it’s not in the law. It lies in voluntary, instead of mandatory, monitoring and oversight.”

For instance, she said, Maryland mandates that prescribing providers must conduct a monitoring visit when prescribing psychotropic medications for foster children.

“So 100% of their kids have a monitoring visit,” Johnson said. “You can’t medicate without it. It’s the only way to ensure proper care.”

Foster children don’t have a political voice, she said, because they’re wards of the state.

“Foster youth have very little political power and will, and unless you mandate it as a state, it’s not going to happen,” Johnson said. “What you see in this county-based system is the state says, ‘We’d like you to do this’ or ‘Will you do this?’ or ‘Could you do this?’ or ‘You should do this,'” she said. “And we’ve got guidelines about it.”

System Reforms Underway

In addition to the recent guidelines, the state is working to reform the system in a number of other ways, according to Will Lightbourne, director of the Department of Social Services.

He said his agency recently held trial reviews at group homes to gauge people’s experiences in psychotropic medication utilization.

“We picked three tiers of group homes,” Lightbourne said, with different rates of prescribing psychotropic medicines. “The purpose of this isn’t to prove anything, more to establish baselines for ourselves as we take the next steps forward.”

The state also recently held a webinar on data sharing to improve communication and oversight, he said.

Funding Withdrawn

Beall withdrew a call for state funding for SB 319, which seeks to establish a public health nurse system in schools to monitor psychotropic medication prescriptions.

The bill passed the Senate and was being held in the Assembly Committee on Appropriations because of the cost of funding the school nurses to make the program function. Beall withdrew that part of the bill, leaving counties to voluntarily take on the task.

Beall said larger counties might still pay for additional oversight responsibilities for school nurses, but smaller counties would have a more difficult time taking on that cost.

The other three bills now are in the Assembly Appropriations suspense file. It’s the last stop before a possible floor vote, but that would need to happen quickly — the current Legislative session ends Sept. 11.

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