Representative Jim McDermott, M.D., Chair
May 8, 2008

“Prescription Psychotropic Drug Use Among Children in Foster Care”

Mr. Chairman and members of the committee, my name is Christopher Bellonci, M.D. and I am pleased to be here to discuss the important issues related to psychotropic medication use among children in America’s foster care system. I am a board-certified child and adolescent psychiatrist and the medical director at Walker, a multi-service agency in Needham, Massachusetts where I work directly with children in the child welfare system. I am a member of the American Academy of Child and Adolescent Psychiatry as well as a member of the Mental Health Advisory Board of the Child Welfare League of America. For several years I have been consulting to the State of Tennessee’s child welfare agency helping that State to revise their policies and procedures regarding psychotropic medication use and behavior management.

As Dr. Zito has outlined in her testimony, children in child welfare appear to be prescribed psychotropic medication at higher rates than children who are not within the child welfare system. In Tennessee, unpublished data indicated that approximately 25 % of the children in that system were taking psychiatric medication. As you have heard from Dr. Zito, her most recent study of children in the Texas child welfare system showed 34.7% of the children were taking psychiatric medications with 41.3% of those children on psychiatric medications taking three or more medications.

One possible explanation for the apparent overuse of psychiatric medications for children in the child welfare population is the high rate of mental illness found in this population. Studies indicate that 60-85% of the children being served by the child welfare system meet criteria for a DSM-IV Psychiatric diagnosis. In many cases this is related to the trauma that resulted in their removal from their family but in a significant number of cases the mental illness appears to have predated their removal. With such a high prevalence of mental illness in this population, screening for mental disorders is superfluous and instead providers time would be better served moving to a comprehensive assessment of the child and family’s strengths and needs that can be used for treatment planning and service delivery.

The families from which these children were removed are often significantly affected by mental illness and substance abuse. These familial conditions lead to a genetic predisposition to mental illness in their children. This risk can be multiplied by in-utero exposure to alcohol and other drugs. Often these children then suffer neglect and abuse compounding their genetic and biological risks to develop emotional and behavioral disorders. Multiple placements within the foster care system add additional burdens to healthy emotional development and impair coordinated mental health treatment. Early detection and assessment of the mental health needs of these children is critical in order for them to receive necessary mental health interventions.

Unlike mentally ill children from intact families, these children rely on the state to provide informed consent for their treatment, to coordinate treatment planning and clinical care, and to provide longitudinal oversight of their treatment. The state has a duty to perform this protective role for children in state custody. However, the state must also take care not to reduce access to needed and appropriate services. Many children in state custody benefit from psychotropic medications as part of a comprehensive mental health treatment plan. As a result of several highly publicized cases of questionable prescribing practices, treating youth in state custody with psychopharmacological agents has come under increased scrutiny. Many states have implemented consent, authorization, and monitoring procedures for the use of psychotropic medications for children in state custody. Unfortunately, these policies can have unintended consequences such as delaying the provision of, or reducing access to, necessary medical treatment.

The critical question in this discussion is whether medication is being prescribed appropriately and ensuring that all of the child’s mental health needs are being adequately addressed. Most psychoactive medications prescribed for children under age twelve do not as yet have specific approval by the Food and Drug Administration (FDA); such approval requires research demonstrating safety and efficacy. Such research, so far, lags behind the clinical use of these medications. Long-term studies are needed to adequately determine the safety and efficacy of psychoactive medications in this age group. In making decisions to prescribe such medications child psychiatrists often are left to evaluate data from studies in adults even though there are documented cases of medications that were safe in adults causing unanticipated side-effects in children. The lack of data supporting current prescribing trends makes the informed consent process all the more important for children in state custody. The prescribing of multiple psychotropic medications (“combined treatment” or “polypharmacy”) in the pediatric population is on the increase. Little data exist to support advantageous efficacy for drug combinations, used primarily to treat co-morbid conditions. The current clinical “state-of-the-art” supports judicial use of combined medications, keeping such use to clearly justifiable circumstances (AACAP policy statement 9/20/01).

In my consulting work in Tennessee, I drafted medication monitoring guidelines for use by that state’s child welfare workers. The guidelines were meant to be used by child welfare caseworkers in their monitoring of psychotropic medications prescribed for children in care. They were not intended to dictate treatment decisions by providers. Every child or adolescent has unique needs that require individualized treatment planning. At times, the appropriate treatment for a specific child will fall outside the parameters of these guidelines. State child welfare agencies need to develop a second opinion capacity for times when prescribing practices fall out of established guidelines or community standards of care. In Tennessee, the state contracted with four university medical centers in four different regions of the state to provide expert second opinion capacity regarding all aspects of a child’s mental health diagnosis and treatment including psychiatric medication.

It was the intent of the following guidelines that children in care receive necessary mental health treatment, including psychotropic medications, in a rational and safe manner. The guidelines reflect common practice wisdom in the field of child psychiatry:

• Medication should be integrated as part of a comprehensive treatment plan that includes:
  • Appropriate behavior supports and treatment
  • Symptom and behavior monitoring
  • Communication between the prescribing clinician and the youth, parents, guardian, foster parents, child welfare case manager, therapist(s), pediatrician, school staff and any other relevant members of the child or youth’s treatment team
• Medication decisions should be appropriate to the diagnosis of record, based on specific indications (i.e., target symptoms), and not made in lieu of other treatments or supports that the individual needs. There should be an effort, over time, to adjust medication dosages to the minimum dosage at which a medication remains effective and side effects are minimized. Periodic attempts at taking the child off medication should also be tried and, if not, the rationale for continuing the medication should be documented.
• Medication decisions need to be based upon adequate information, including psychiatric history and assessment, medication history, medical history including known drug allergies and consideration of the individual’s complete current medication regimen (including non-psychoactive medications, e.g., antibiotics).
• Polypharmacy, or the use of multiple psychiatric medications, should be avoided.
• When a recommendation is made for a child to take more than one medication from the same class (e.g., two anti-psychotic medications), the recommendation should be supported by an explanation from the prescribing clinician and may warrant review by a consultant to the child welfare system.
• A child taking more than three psychotropic medications should prompt an explanation from the prescribing clinician and may warrant review by a consultant to the child welfare system.
• Medication dosages should be kept within FDA guidelines (when available). The clinical wisdom, “start low and go slow” is particularly relevant when treating children in order to minimize side effects and to observe for therapeutic effects. Any deviations from FDA guidelines should be supported by an explanation from the prescribing clinician and may warrant review by a consultant to the child welfare system.
• Unconventional treatments should be avoided. Medications that have more data regarding safety and efficacy are preferred over newly FDA-approved medications.
• Medication management requires the informed consent of the parents or guardians (unless parental rights have been terminated in which case the state must provide informed consent) and must address risk/benefits, potential side effects, availability of alternatives to medication, prognosis with proposed medication treatment and without medication treatment and the potential for drug interactions.
• The risk versus benefit of a medication trial needs to be considered and continually reassessed, and justification should be provided, where the benefit of a medication comes with certain risks or negative consequences.
• Children on psychotropic medications should be seen by their prescribing clinician no less that once every three months. This is a bare minimum and children in acute settings, displaying unsafe behavior, experiencing significant side effects, starting on SRI’s or not responding to a medication trial or in an active phase of a medication trial should be seen more frequently.
• If laboratory tests are indicated to monitor therapeutic levels of a medication or to monitor potential organ system damage from a medication these lab studies should be performed every three months at a minimum (maintenance phase). If the medication is being initiated, these lab studies will need to be performed more frequently until a baseline is achieved.

In addition to developing the guidelines, a computerized, interactive state-of-the-art training curriculum was developed for all child welfare staff in Tennessee. The curriculum used clinical vignettes to teach child welfare staff about the revised psychotropic medication policies and procedures as well as the medication guidelines. The Department is also working to update its information technology system to be able to embed the guidelines into their database so that when a child’s psychiatric medications fall out of the guidelines an alert is sent to the case manager or supervisory staff. This system would work similar to a pharmacy’s computer program alerting the pharmacist to possible medication contraindications.

State child welfare agencies should create websites that can provide ready access for clinicians, foster parents, and other caregivers to pertinent policies and procedures governing psychotropic medication management, psycho-educational materials about psychotropic medications, consent forms, adverse effect rating forms, reports on prescription patterns for psychotropic medications, and links to helpful, accurate, and ethical websites about child and adolescent psychiatric diagnoses and psychotropic medications (AACAP Position Statement on Oversight of Psychotropic Medication Use for Children in State Custody: A Best Practices Guideline).

States should develop the capacity to monitor the rate and types of psychotropic medication usage by children in state care as well as the rate of adverse reactions to prescribed medications. States should establish a process to review non-standard, unusual, and/or experimental psychiatric interventions with children who are in state custody. States should collect and analyze data and make quarterly reports to the state or county child welfare agency regarding the rates and types of psychotropic medication being prescribed to children in their care. Making this data available to clinicians in the state could serve as a vehicle to improve the quality of care provided to children in state custody.

Thank you for the opportunity to address this important area of concern impacting America’s most vulnerable youth.