There is currently a much-needed national spotlight on the high rates of psychotropic medication use among children and youth in foster care, most of whom receive health coverage through Medicaid.
This high-risk population is far more likely to receive psychotropic medications, including antipsychotics - a class of medication with serious side effects - than the Medicaid child population overall. While there are certainly some children and youth who should receive these medications, states must have oversight and monitoring mechanisms to determine when this is - or is not - the case.
This high-risk population is far more likely to receive psychotropic medications, including antipsychotics—a class of medication with serious side effects—than the Medicaid child population overall. While there are certainly some children and youth who should receive these medications, states must have oversight and monitoring mechanisms to determine when this is—or is not—the case.
Many of these children and youth experienced trauma before and because of removal from their homes. As a result, they are likely to need behavioral health services — but, not necessarily psychotropic medications, or specifically, antipsychotics. A number of factors contribute to the potential for inappropriate psychotropic prescribing practices:
- A lack of access to effective non-pharmacological interventions and a reliance on medications to quickly control difficult behaviors;
- An inadequate supply of child behavioral health specialists with training in evidence-based, trauma-informed practices;
- Limited clinical knowledge among child welfare case workers about appropriate psychotropic medication use;
- A lack of coordination across providers and child-serving agencies; and
- Aggressive, effective pharmaceutical marketing and financial incentives that drive prescribing.
Recognizing this issue, a joint November 2011 letter from the Centers for Medicare and Medicaid Services (CMS), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Administration for Children and Families (ACF), encouraged states to strengthen oversight of psychotropic medication use among this high-risk population.
Lessons From States To Improve Psychotropic Medication Oversight And Monitoring
Over the past three years, the Center for Health Care Strategies (CHCS), through support from the Annie E. Casey Foundation, worked with six states in a collaborative focused on improving psychotropic medication oversight and monitoring. The following are key lessons:
Understanding how psychotropic medications are paid for is critical to monitoring utilization and performance.
Control of these dollars may sit in the Medicaid agency or state behavioral health agency, or may be the responsibility of state-contracted managed care organizations. These agencies should be at the table when designing oversight and monitoring programs to leverage agency capacity and contractual authority.
Stakeholder perspective is important for tailoring programs effectively.
Including diverse perspectives in the development of an oversight and monitoring system leads to fewer “blind spots.” Texas’ child welfare agency convened an Advisory Committee on Psychotropic Medications—comprised of child and family advocates, foster parents, providers, youth in foster care, and human services professionals—to help guide its strategy.
Data should be aggregated across systems for a comprehensive picture of use.
Data—which often reside in disparate agencies—are needed to:
1.determine baseline rates of psychotropic medication use and expense;
2.identify outlier prescribing patterns;
3.understand the types, number, and quantity of psychotropic medications prescribed; and
4.track quality and cost outcomes.
Investments to change prescribing patterns are most effective when targeted to high-priority providers or high-risk cohorts of children. New Jersey is examining child welfare, Medicaid, and children’s behavioral health data to develop a clear picture of both psychotropic medication use and that of psychosocial interventions. The state is also enhancing its child welfare data information system to capture data on psychotropic medication use.
Mechanisms for system-level oversight and child-level monitoring are needed.
Determining criteria for appropriate medication use and maintaining oversight of outlier prescribing patterns are critical. Collecting and reporting key metrics regularly can help determine whether prescribing complies with state and/or national clinical practice guidelines and drive more effective practices. Common measures and definitions can help states identify system-level metrics for tracking. Oregon developed dashboard reports for its coordinated care organizations that capture provider patterns of psychotropic medication prescribing. New Jersey now trains case workers and nurses in its child health unit to continuously monitor the behavioral health needs of children receiving psychotropic medications.
Improving access to evidence-based psychosocial interventions and understanding the role of trauma is essential.
In some cases, providers may rely on psychotropic medication because access to evidence-based psychosocial interventions is limited. Increasing the availability of evidence-based practices may stem this trend. Rhode Island has implemented a number of practices to encourage non-medication interventions, including: Trauma Systems Therapy; Cognitive Behavioral Therapy; and the Positive Parenting Program. Additionally, childhood trauma can have behavioral manifestations that are misdiagnosed — often as attention deficit hyperactivity disorder (ADHD) or aggression.
An effective trauma screening process and use of trauma-informed interventions can reduce the likelihood that a child will be inappropriately prescribed psychotropic medication. ACF has issued three rounds of grants to states to improve screening for and treatment of trauma among children involved in child welfare, including those in foster care.
Informed consent should include clinical expertise.
In many states, the child welfare agency must consent to the use of psychotropic medication for children in foster care. Clinical expertise—either consulting or staff psychiatrists or other mental health professionals—for review and prior authorization must be available. In Illinois’ legislatively mandated clinical review process, clinicians at the University of Illinois at Chicago review all psychotropic medication requests.
States like California have recently enacted policy changes to curb inappropriate prescribing of psychotropic medications by requiring extra oversight — particularly for children in foster care. A recent congressional briefing, held to inform legislators around this issue, highlighted two key messages: (1) children in foster care remain at high risk for overuse of psychotropic medications; and (2) children with serious behavioral health needs should have access to evidence-based psychosocial interventions to reduce reliance on psychotropic medications.
The policies outlined above can help states monitor and address these concerns and advance improvements in care for children and youth in foster care