Five years after state officials determined foster children were prescribed psychotropic drugs more often than other kids, there’s still no way to know whether the state has narrowed the gap.
Child advocates and a state legislator have pushed for heightened scrutiny of prescription drug rates for children in Arizona’s overwhelmed child-welfare system.
For years, state officials have promised to repeat a 2011 study that found Arizona’s foster children were 4.4 times more likely than non-foster kids to be prescribed psychotropic drugs including antidepressants, antipsychotics, ADHD drugs, mood stabilizers and anti-anxiety drugs.
In February the Star, which reported on the problem in 2014, requested updated data on how often foster children are prescribed psychotropic medications compared with other children.
Monica Coury, spokeswoman for Arizona Health Care Cost Containment System — the state’s Medicaid program — said the study would be done in a few weeks. Then in March, she said it would be done by the end of the month. Most recently, Coury said it should be released at the end of April.
Two years ago, the chief medical officer of the Arizona Division of Behavioral Health Services told the Star it would produce such a report within six months.
A state lawmaker said she asked for the study to be done in 2013, but state health officials never provided one, even as they kept saying it was in progress. State Sen. Debbie Lesko, R-Peoria, went so far as to introduce legislation requiring the release of a study.
“It is disappointing to me that an agency does not follow through with their promises,” Lesko wrote in an email.
Booming FOSTER POPULATION
Child advocates are concerned that the state’s exploding foster-care population could overwhelm case workers, foster parents and doctors, potentially leading to more reliance on drugs and less on more time-consuming alternatives like therapy to help control disruptive behavior.
The foster population has swelled to more than 18,000, an increase of nearly 50 percent since 2012.
State Sen. David Bradley, D-Tucson, who has worked with foster children and mental-health care for three decades, said the influx of children into the state’s foster-care system has strained the ability to effectively treat each one.
The number of kids in the system “doesn’t allow a lot of time for evaluation to determine whether a child needs to be on psychotropic meds,” Bradley said.
The drugs aren’t without risks, carrying side effects ranging from weight gain, an increased risk of suicidal behavior with antidepressants to several neurological side effects with antipsychotics.
NOT COMPARABLE STUDY
Last year, Lesko sponsored a bill that would have required AHCCCS to publish data comparing the psychotropic drug prescription rates of foster children and non-foster children eligible for Medicaid every two years. Senate Bill 1297 received unanimous approval by the Senate, but was voted down in the House Committee on Children and Family Affairs.
During a Senate hearing, Lesko said she met with state health officials in 2013 after hearing concerns that foster children could be over-medicated. They told her they would produce an updated report comparing rates of prescriptions between foster and non-foster children.
“They kept saying that they were going to get me an updated report and that they were working on it,” she told the Senate Health and Human Services Committee in February 2015. “I ultimately became frustrated and said, ‘You know what, I’m just going to put it in legislation that we need a report.’”
While the bill failed, AHCCCS officials told lawmakers they would produce a report replicating the original study by August 2015.
But the study AHCCCS released in October, based on 2014 data, only looked at foster children without comparing them to non-foster children. Coury said the new findings are not comparable to the study based on 2008 data because its methodology differed from what AHCCCS used.
The 2014 study found about 15 percent of Arizona foster children were prescribed psychotropic medications. That rate increases to about one in four foster children between the ages of 6 and 17 who were prescribed psychotropic drugs.
More than 250, or 2.5 percent, of foster children ages 5 and under were prescribed some type of psychotropic medication, mostly for ADHD.
Also in the report, 741 children were being prescribing two or more psychotropic medications simultaneously. Thirty-four of them were prescribed five or more at once. A Government Accountability Office study on psychotropic drug prescription rates for foster children called that a “high-risk practice” that increases the chances of “adverse reactions.”
“There’s not strong evidence for prescribing more than two or even more than one medication to kids,” said Dr. Kathy Smith, the director of the Division of Child and Adolescent Psychiatry at the University of Arizona College of Medicine.
Experts say that given the trauma many foster children experience, it’s expected that they would receive psychotropic medications more often than non-foster children. But some worry that the drugs are being used instead of other treatments.
The 2011 GAO report found that only 20 percent of foster children who would have benefited from these types of services received them.
“We want them to get the right services,” said Beth Rosenberg, director of child welfare and juvenile justice policy at the Children’s Action Alliance, an Arizona advocacy group. “We don’t want them to just be medicated.”
In 2011, the GAO found foster children in five states were prescribed psychotropic medications 2.7 to 4.5 times more often than non-foster children.
The report, based on 2008 data, prompted Arizona to conduct its own study. It found 11.3 percent of the state’s foster children were on a psychotropic medication and were much more likely to receive the drugs than non-foster children.
Following the release of the report, Arizona health agencies announced oversight measures to ensure foster children are properly being prescribed the drugs.
AHCCCS formed an oversight team, and sought to improve foster children’s understanding of their diagnoses and prescriptions and began monitoring doctors’ prescribing habits.
“It’s a continued work in progress,” said Dr. Sara Salek, chief medical officer for AHCCCS.
Regional Behavioral Health Authorities, or RBHAs, are responsible for monitoring psychotropic drug prescriptions to foster children and submitting data to AHCCCS. The RBHA for Southern Arizona is Cenpatico Integrated Care, which took over from the Community Partnership of Southern Arizona in October.
An array of state health agencies formed the Arizona Psychotropic Monitoring Oversight Team in response to concerns over-medicated foster children.
A public-records request seeking minutes from the team’s meetings produced documents from one meeting, which half of the members attended. Coury said the team also met other times, but she could not say how many times.
The team stopped meeting as the state goes through a shift in its behavioral-health structure, and its functions are still being carried out within AHCCCS, Coury said. The Division of Behavioral Health Services is in the process of moving into AHCCCS, which
is focusing on improving coordination of medical and behavioral-health care through an “integrated” care model.
The agency also monitors doctors to ensure no one is overprescribing psychotropic medications. Doctors can be referred to a peer review committee for investigation, Salek said. But Coury couldn’t say how many times, if any, that has happened.
OPTIONS FOR TREATMENT
Alicia Lopez had no choice but to keep taking her antidepressants.
Lopez entered the foster-care system when she was 2 after her mother died and her father was incarcerated. She lived with a foster family until she was 14, but left after a school counselor discovered abuses at her home. She was then shuffled through five group homes around Tucson.
A doctor prescribed antidepressants for her.
“When I was on the medications, it really didn’t help,” Lopez, 18, said. “I felt like I was being happy for the wrong reasons.”
Getting off antidepressants took about a year because she needed to work with her doctor and her CPS case worker, who had 30 other foster children to cover, Lopez said. The situation at the group home wasn’t helping, either.
“If we refused (to take prescribed medications) in the group home, they would remove your privileges,” she said.
Guidelines from the American Academy of Child and Adolescent Psychiatry say attaining consent from the child when prescribing treatment is important to his or her behavioral-health treatment, said the UA’s Smith.
“We should be following those guidelines and asking those kids, ‘How do you feel about taking this medicine?’” Smith said. “We would do the same consenting process for kids that we do with adults, even though they don’t have the same legal rights.”
In many cases, psychotropic drugs are needed for a foster child, particularly one who has experienced trauma, said Salek, of AHCCCS.
“On top of that you have the removal in and of itself,” she said. “Being removed from the family unit is a very traumatic event.”
Lopez recently moved in with her cousin and his wife on Tucson’s west side and is a senior at Tucson High School. The move, she said, has given her a stable environment after spending three years in group homes.
At school, Lopez frequently stays after class to work on anatomy and physiology. “Our bodies are incredibly complicated systems,” she said, and she wants to understand them.
Once she graduates, Lopez plans to attend the University of Arizona to study neurology and eventually go on to medical school.
The brain, she said, fascinates her.