Concerns Over Antipsychotic Drug Prescriptions for Foster Kids Spur Potential Legislation

By Rebecca Adams, CQ HealthBeat Associate Editor  December 1, 2011

Sens. Scott P. Brown and Thomas R. Carper plan to write bipartisan legislation to reduce the risks that children in foster care would be inappropriately prescribed psychotropic drugs.


At a hearing before the Committee on Homeland Security and Governmental Affairs, Bryan Samuels, commissioner of the Department of Health and Human Services’ Administration on Children, Youth and Families, said that HHS would give the panel recommendations on what to include in a bill and would try to steer states to do more to prevent overmedicating foster children.


The moves come after a new Government Accountability Office (GAO) report raised concerns about the use of psychiatric drugs in foster care children. Babies were given medication for mental illness, according to the report, even though the drugs could be harmful to young children. A medical expert testified at the hearing that he could not think of any situation in which a baby would need a psychiatric drug.


Thousands of children who live in the five states that the GAO studied were given high doses that could be unsafe. And hundreds of children were taking five or more drugs at one time, even though the GAO said that there is no medical evidence that a regimen of so many medications was safe or effective.


The drugs are often paid for by Medicaid, the federal-state program for low-income earners.
Samuels said that Health and Human Services officials would comply with the GAO recommendation to issue a guidance to state Medicaid and child welfare agencies explaining the best practices for monitoring the use of psychiatric drugs in foster children. But Samuels said that Congress would have to intervene with legislation before HHS could issue a national standard that all state Medicaid agencies would have to follow. Carper, D-Del., and Brown, R-Mass., encouraged him to send them ideas for a bill soon.

Foster Child Testifies

The hearing featured a 12-year-old boy who had been in foster care until he was adopted a few years ago. The boy, Ke’onte Cook, said he had been given about 20 drugs during his life and had taken as many as five at the same time. He had been given little explanation of what the drugs were for. His former foster parents had told him that he had been diagnosed with attention deficit hyperactivity disorder after he threw tantrums. But the boy also received drugs for bipolar disorder and seizures, which he had never experienced. Cook called the multiple prescriptions the “most idiotic” thing that had happened to him in foster care.


“Meds aren’t gonna help a child with their problems,” he said. “It’s just going to sedate them.”
Ke’onte’s adopted mother, Carol Cook, said she had been concerned about the number of drugs he was taking. “He was just lights out,” she said, acting like a zombie within 15 minutes of taking some of the medication.


After Cook and her husband adopted Ke’onte, they decided with a pediatrician to wean him off all of the drugs. The process was not easy.


“He was very interesting the first few months,” she said with a wan smile. He would scream and cry for no apparent reason, she said.


But after a few months, his behavior improved significantly.
“He went from break dancing on the principal’s desk in her office to not going to the principal’s office for a whole month,” she said. From the time the boy entered school at his new home in January until the summer break in May, “he was almost a different child.”


Sen. Tom Coburn, R-Okla., a doctor, said he had studied the boy’s prescription protocol and found that two of the five drugs that the boy had been taking had the opposite effect as the other three. Coburn also said that three of the drugs were not approved for children.


After Ke’onte testified, the audience clapped. He gave Carper a hug and fist bump as he left the room.
Brown said he was “heartbroken” by Ke’onte’s testimony and said he “really was shocked” by the findings in the GAO study.

Report Findings

The GAO found that in all of the five states evaluated — Massachusetts, Florida, Michigan, Oregon and Texas — foster children were at greater risk of inappropriate medication use than children who were not in foster care. Brown said he is sending a letter to Massachusetts officials asking for an explanation.


The rate of foster children who were prescribed five or more psychiatric drugs simultaneously was 0.11 percent to 1.33 percent in the five states, compared to rates of .01 percent to .07 percent among non-foster children in the states studied. GAO investigator Gregory Kutz said the use of five or more drugs is a “high-risk practice.” The report said that “only limited evidence supports the use of even two drugs concomitantly in children.”


Foster children also were given higher doses of the drugs than is considered safe. About 1.12 percent to 3.27 percent of children in foster care were given levels that were higher than the maximum recommended dosage, compared to 0.16 percent to 0.56 percent of children in other types of homes.
And 0.3 percent to 2.1 percent of babies in foster care were prescribed a psychotropic drug, compared to 0.1 percent to 1.2 percent of other children. Some of the anti-anxiety drugs could have been prescribed for physical rather than mental problems, the GAO said. But the report said that “these cases raise significant concerns because infants are at a stage in their development where they are potentially more vulnerable to the effect of psychotropic drugs.”


Samuels said in his testimony that a 2010 study of children in 13 states showed that foster care children in Medicaid were prescribed antipsychotic medications at nearly nine times the rate of children in Medicaid who were not in foster care.


One change that Medicaid directors in some states could make would be to require prior authorization of the drugs before Medicaid will reimburse for them, if state law allows that. In some states, said Matt Salo, executive director of the National Association of State Medicaid Directors, legislatures have banned prior authorization under pressure from drug companies that make the drugs, patient advocates or a general public that is wary of government interference in the physician-patient relationship. Even in those states, however, electronic systems could be established that would issue a warning when certain types of prescriptions are filled.


Samuels said that in his previous experience as child welfare director in Illinois, the state built an electronic database that tracked the prescriptions that foster children received, which made it easier to identify problems.


All of the witnesses said that some type of additional oversight should be undertaken.
“Clearly, we need to do better,” Salo said.