Improving Psychiatric Treatment for Kids in Foster Care

On October 1, three years after the federal government called on states to better monitor the use of psychotropic medications in foster children, California’s Department of Health Care Services took action. They began requiring that state pharmacists verify the “medical necessity” of antipsychotic prescriptions before the medications can be given to children who are 17 and younger and covered by Medi-Cal, the state’s health program for the poor that also includes foster children.

This new restriction came shortly after the San Jose Mercury News published an investigation that found nearly one in four adolescents in the child welfare system is prescribed at least one psych med — three and a half times the rate of all teens. The newspaper also found that almost 60% of foster youth prescribed psychotropics in California are given antipsychotics and concluded that “many of the medications are prescribed for behavior management — not the mental illnesses they are approved to treat.”

California is not alone in this issue. Almost all states have some form policy or guideline for psychotropic medication use in foster children. While a large percentage of states report “quality improvement” as one reason for this strategy, other reasons include legislation, media coverage, and lawsuits prompting change.

As state lawmakers express outrage and social activists vow to force tighter restrictions and more oversight on psychotropic medication prescribing to foster children, those of us who simply practice child psychiatry are left with some pretty tough questions. Mainly, what is behind this questionable prescribing? And what can we do as providers to advocate for our patients? 

We should be seen as the champions of initiatives to protect our patients from less than ideal prescribing practices, not as villains used in broken systems only to medicate children recklessly for monetary gain or to appease foster care providers and school administrators. 

The truth of the matter is that despite ongoing research that suggests that comprehensive treatment approaches are more effective and generally provide better outcomes in children, the reimbursement structure in our health care systems rarely supports this treatment strategy. Consequently, child psychiatrists are often times forced to practice psychiatry in less than ideal treatment models that offer the lack of support and collaboration needed for the best quality of care for their patients. 

However, child psychiatrists must not succumb to the system. Instead, we have an obligation to stay current with our knowledge base and hold fast to the fundamental truth that child psychiatry is much more than prescribing medication to children simply to treat behavior. Regardless of the treatment models that we find ourselves working in, we should always take the time we need to thoroughly investigate all the relevant factors implicated in the development of a patient’s problem, including biological, psychological, social and cultural perspectives as we develop our treatment plans.

And when we conclude, as is often the case, that other factors need be addressed prior to the start of medication, we must always formally document those recommendations, and actively advocate with other providers and stakeholders in the child’s life to ensure that appropriate and recommended treatment occurs. 

The alternative is beyond problematic. Prescribing medication to children — especially our nation’s most vulnerable children — without the appropriate systems and support in place puts our patients at risk for poorer outcomes, and puts child psychiatrists at risk to be targeted as scapegoats in a larger system issue. 

Along with the American Academy of Child and Adolescent Psychiatry, as noted in the practice parameter, “Prescribing Psychotropic Medication to Children,” I do not advocate for restricting access to medication treatment for those patients for whom it is appropriately indicated. Rather, I favor high-quality assessment and prescribing practices to enhance outcomes for children and to address societal concerns about how children with psychiatric disorders are treated. 

As professionals, let us firmly commit to better educating ourselves, following our treatment guidelines, and advocating for the systems and treatment models that we need to provide quality care for our patients. Moving forward, let us champion the improvements that our patients and our nation need to see in this area remembering that we have the power to change the way this story is written in the future.

Melissa Vallas, MD, is lead psychiatrist at Children’s System of Care, Alameda County (California) Behavioral Health Care Services Agency.