Special Report

Care Concerns

Advocates say overmedication of foster care children still a problem

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Nearly a decade ago, the Indiana Department of Child Services and Indiana Family and Social Services Administration acknowledged a problem: too many children in foster care were getting psychotropic medication instead of mental healthcare.

Nearly a decade ago, the Indiana Department of Child Services and Indiana Family and Social Services Administration acknowledged a problem: too many children in foster care were getting psychotropic medication instead of mental healthcare.

The agencies launched the Indiana Psychotropic Medication Advisory Committee in 2013, vowing to increase oversight and make policy recommendations. Just one year earlier, nearly 30% of the 400,000 children in foster care received at least one psychotropic medication, which can treat depression, bipolar disorder, schizophrenia, attention deficit/hyperactivity disorder, post-traumatic stress disorder and anxiety disorders.

But foster families say that overmedication of children is still a problem.

In early August, Allison Missler, a foster parent, testified before a House committee that children arrived at her door with multiple prescriptions and little else.

“It has been my overwhelming experience that the state prefers to medicate children then find non-pharmacological, trauma-informed treatment,” Missler told the Ways and Means committee.”Most children arrive at my home with a Ziploc bag of medications: medications to wake them up, to help them focus, to stabilize their moods and then to make them sleepy.”

While considering legislation to bolster the state’s lagging foster care system in anticipation of increased need following a ban that would curtail more than 95% of abortions, Missler urged the committee to do more for the state’s most impoverished. She said the state’s per diem for families, $21, was less than the cost of her parking in downtown Indianapolis that day and half what it cost to board her dog.

“We have to stop planning and start doing. We are going to lose a generation,” Missler told lawmakers.

A Department of Child Services spokesperson acknowledged receiving a list of questions from the Indiana Capital Chronicle on Aug. 18 but said the department didn’t have anyone available for an interview. The department did not respond to the emailed questions.

Prescription rates for foster children

Indiana’s foster children continue to have high rates of medication, according to the latest analysis available.

An independent evaluation of the state’s Psychotropic Consultation Program in 2017 identified “outlier cases,” or instances where foster children had six or more prescriptions, had a prescription for someone under four years of age or had a prescription for something not approved for use in children.

An Indiana University physician consulted the child’s doctor in 605 outlier cases over two years and reported decreasing the number of prescriptions and monthly healthcare expenditures.

Yet as recently as 2018, Indiana medicated more than one in four children in foster care, or 28.6% of its 23,912 children, higher than the national average of 22.2%. Illinois, which had double the number of children in foster care, 53,898, only treated 18.8% with medication and spent nearly $4 million less on psychotropic expenditures.

The report, from the Office of Inspector General for the U.S. Department of Health and Human Services, determined that more than one-third of American children in foster care didn’t receive treatment planning or medication monitoring.

“Treatment planning is critical to enhancing continuity of care; improving coordination of services between health and child welfare professionals; and reducing the risk of harmful side effects,” the report advised. “Effective medication monitoring can reduce the risk of inappropriate dosing and inappropriate medication combinations.”

OIG observed that up to 80% of children enter foster care with “significant” mental health needs and while medication can effectively treat some children, those same drugs can have serious side effects.

Without a family member acting as an advocate, no one person oversees a foster child’s mental health treatment, risking miscommunication, conflict and a lack of followup. Health information may not follow the child through various living situations and they may receive incorrect doses, too many medications and other inappropriate treatment as a result.

The report urged the Administration for Children and Families, which oversees foster care administration on the federal level, to adopt a comprehensive strategy to decrease reliance on the medication with states, but identified the issue as one of the top 25 unimplemented recommendations in 2021.

“ACF plans to undertake several actions to improve States’ compliance, including requesting that States report on successes and challenges in addressing psychotropic medication use requirements,” the 2021 release evaluating the status of unimplemented recommendations said. “ACF plans to provide guidance for those States that must develop improvement plans in this area.”

Shortage of mental health providers

Any adult caring for a child with mental health needs to learn how to better understand and appropriately respond to their child’s struggles, said Chris Daley, the executive director of the Indiana Association of Resources and Child Advocacy.

But Indiana has a shortage of mental health providers overall, and in youth care specifically.

“I think the most difficult piece in Indiana, for any kind of youth emotional well-being, is finding providers who are able to provide services,” Daley said. “Some of them do have a greater need for services - whether they’re living with their parents, with a kinship or foster parents or in a residential agency. In every single one of those settings we struggle to be able to find and keep enough licensed practitioners to meet their needs.”

According to the Kaiser Family Foundation, just over one-third of Indiana’s mental health needs are met, with 4.7 million Hoosiers living in designated Mental Health Care Health Professional Shortage Areas. The foundation estimates Indiana would need nearly 200 more providers to close that gap.

Foster children, perhaps partially due to their instability at home and life histories, are almost four times more likely to have considered suicide or have attempted suicide than children outside of the foster care system, according to youth.gov, a federal interagency group of programs and services for youth.

Because of this, adults caring for foster children need to be extra cognizant but might be at a loss themselves. And while medication can play a role in mental healthcare, it has its limits. But a foster child, often without one adult keeping a watchful eye on their medication, can fall between the cracks.

In particular, healthcare providers encountering traumatized children might not know the best treatment strategies. Many of the drug treatments common for adults aren’t even proven to be effective in children, and may have negative consequences.

“No one wants children to be over medicated so I think there’s a lot of support for that work. I think there’s just still some work to do on figuring out how,” Daley said. “There’s probably a way to thread that needle, we just haven’t figured it out yet.”