Michigan's prescription for foster kids: drugs

Taxpayers have spent more than $70 million in a single year in Michigan on psychotropic drugs for foster kids and other children on Medicaid. And, nearly a quarter of Michigan foster kids were on psychotropic drugs to counteract behavioral problems and diagnosed mental illness in 2008, according to a recent government report.

That report comes as some scientists are concluding such drugs are over-prescribed to children.

“The medication is a quick fix,” says Detroit foster mom Jannie Johnson, regarding children needing psychotropic medications to treat conditions such as anxiety, depression, and bipolar disorder. “There are a lot of bad side effects."

A report from the Government Accountability Office last December stated that foster children are twice as likely to be prescribed psychotropic drugs -- medications for anti-anxiety, Attention Deficit Hyperactivity Disorder (ADHD), depression, psychosis -- than other children on Medicaid. The reasons include greater exposure to trauma, frequent changes in placements and varying state oversight policies, the GAO said in a review of five states, including Michigan.

Twenty-one percent of the state’s foster children were prescribed psychotropic medications in 2008, while 7.9 percent of nonfoster children were, the GAO found. While most of the prescriptions were to children ages 6 to 17, 4.4 percent of foster children under age 5 were prescribed a psychotropic drug.

By comparison, a separate study by the Children's Hospital of Philadelphia of nationwide data between 2002 and 2007 found psychotropics prescribed for one in six foster children.

Dr. David Rubin, director of PolicyLab and attending pediatrician at Children’s Hospital of Philadelphia, said the goal of the hospital's article was to start a conversation about types of treatment available for children in mental health systems. Some communities are limited to providers only offering basic psychiatric treatment, or “med checks.”

“In that type of environment, it’s common to have that type of drug use to control behaviors. We’re hoping that the article prompts a response at the state level and in communities to think about other types of treatment options -- to broaden other options for families.”

Michigan spent $72.8 million through Medicaid to pay for psychotropic medications prescribed to foster and nonfoster children during 2008. Michigan had just over 20,000 children in the foster system at the end of 2008; an additional 913,000 children were in the Medicaid system, according to state figures.

Foster care populations by state, 2002-2010

Foster parents such as Johnson have seen firsthand what happens when a child is separated from a parent, and is left to deal with the multitude of issues that can follow. Johnson has cared for foster children -- mostly infants and toddlers -- for the past 23 years, adopting three of them. One of her adopted daughters required both medication and therapy to manage what Johnson called a “very severe” case of ADHD, while the other two adopted children only needed therapy.

Dr. Jeanette Scheid, a psychiatrist with the Michigan Department of Human Services, told Bridge via email that the GAO report is correct that more foster children are being prescribed psychotropic drugs than nonfoster children, and that more research must be done to determine why.

Scheid said many children in Michigan’s foster care system have a higher genetically based propensity for psychiatric disorders on top of more exposure to abuse, separation from loved ones and separation from support systems such as schools and medical providers.

“Research findings have shown clearly that each of these factors increase the risk of developing psychotropic disorders and that exposure to multiple factors multiplies the risk,” Scheid stated. “Each of these complicating factors might explain the differences in prescribing patterns. However, it is critical to develop systems that respect and attend to the complex needs of youth and families in DHS.”

Among the GAO's other findings:

* Michigan was the only state of the five examined that does not have established training requirements for child welfare, court personnel or foster parents to make them advocates.

* Michigan does have policies identifying who can give consent for medicating foster children, but there is no standardized consent form to help inform consent decisions.

* Michigan meets only one of the guidelines recommended, but not mandated, by the American Academy of Child and Adolescent Psychiatry.

* 1.5 percent of Michigan’s foster children under age 1 were prescribed a psychotropic drug, compared to 0.3 percent of children on Medicaid who are not in the foster system. (Researchers did note that some of the medications in the psychotropic drug category, such as antihistamines, could have been prescribed to treat a non-mental health issue such as allergies or a rash.)

* Michigan foster children under age 17 were three times more likely than for non-foster Medicaid patients to receive drugs at dosages exceeding maximum guidelines based on FDA-approved labels.

* Michigan foster children were far more likely to have five or more psychotropic prescriptions at the same time than non-foster Medicaid patients. “Increasing the number of drugs used concurrently increases the likelihood of adverse reactions and long-term side effects, such as high cholesterol or diabetes, and limits the ability to assess which of multiple drugs are related to a particular treatment goal,” the GAO authors noted.

"The nurturing and one-on-one contact that the foster parent does matter," said Johnson. "A lot of these things can be minimized if you put in the time and work with that child; you can overcome practically anything. They will give the drugs if you allow them to. I feel like if you medicate a child at an early age, you don’t know what the problem is. If the child is doped up, the child can’t let you know."

In January, DHS released a medication policy that requires documentation of diagnosis, treatment target, medication side effects and alternative treatment options. The policy also requires a signature of an authorized person before new medication is given, requires guidelines for maintaining the medication regimen, and outlines an oversight procedure. The Michigan Department of Community Health also has launched an oversight pilot program for all Medicaid recipients.

“These initiatives, as well as efforts to improve the coordination of care across systems, are intended to ensure that DHS, working with its partners in the Department of Community Health and private agencies, will achieve the goal that DHS youth will have access to high-quality assessments and appropriate treatment,” Scheid said.

Natasha Robinson is a freelance journalist based in Lansing, who has covered education in North Carolina and interned at several Associated Press bureaus. She works for the Michigan Primary Care Association.