With Obama’s Medical Reform Bill under scrutiny at this time, I thought it was important and relevant to look at its effects on our families, children, and especially, the foster care system.
In 2004 Carole Strayhorn launched an investigation into Texas Foster Care System, and found an alarming amount of foster children were given psychotropic medications. Most of these medications were not approved by the FDA for use on children, and were being given in high doses to children as young as 2 years old. The States’ Medicaid program paid the costs.
This investigation took years to take place by the constant barricades put up by Governor Perry and DHHS in reporting true figures by which the investigators could look into. By the time the investigation was complete, the findings were shocking, and Senate Bill 6 addressed the concerns as it was created to reform the Child Welfare System.
Though many programs and laws were created, they were not, as of 2006, implemented.
I am currently researching the current status, and also reviewing the proposed Health Care Reform bill, myself, to see what I mght find. According to news reports I read, it does seem to open the doors to further CPS involvement in families, allowing them easier access in a “home visitation program” for expecting women in impoverished areas.
This concerns me.
In case you are not aware of what was going on with our foster children in the arena of psychotropic medications in foster care, here’s some excerpts from Carol Strayhorns Report of 2006 following her investigation.
Keep on reading deep into whats really going on, these children are counting on us to stop these atrocities. Please. My son was one of them.
What if it was your child?
Excerpts from Report of December 14,2006 issued by Texas Comptroller Chairman, Carol Strayhorn, Medicaid and Public Assistance Fraud Oversight Task Force
This report reveals a number of significant medical concerns within the state’s foster care system.
Lack of Medical Histories
DFPS still (as of 2006:) does not provide its foster children with a “medical passport” explaining their medical history, including diagnoses and prescriptions although the passport is required by law.
Instead, foster children often move from one placement to another, seeing new physicians or counselors who have little or no knowledge of their past medical histories. A medical passport would help provide more consistent care for these children.
In September 2006, DFPS stated that it “is working with HHSC on the development of the health passport, scheduled to be implemented September 2007”— more than three years after the Comptroller’s first published recommendation. Psychiatric Hospitalizations DFPS has no rules, guidelines or monitoring procedures concerning the psychiatric hospitalization of foster children.
In fiscal 2004, 1,663 Texas foster children were hospitalized for psychiatric care for a total of 33,712 days, at a cost of $16 million based on daily rates of more than $500 per day.
DFPS has no rules, guidelines or monitoring procedures concerning the psychiatric hospitalization of foster children.
More than 400 foster children spent than a month each in psychiatric facilities in fiscal 2004. Some of these foster children were “dumped” into psychiatric hospitals, by foster parents who decided that they could not deal with the child’s behavior.
DFPS caseworkers often left foster children in such facilities long after they were authorized for release.
Medically Fragile Children
The Comptroller’s office e(stimates that about 1,600 “medically fragile” children were in Texas foster care in fi scal 2004. These children have serious and continuing medical conditions requiring specialized care and treatment. About 49 percent of them were four years old or younger.
Many of these children were in “basic” service-level homes, because DFPS places more emphasis on behavioral conditions than on physical conditions and needs.
HIV and AIDS
DFPS has been particularly negligent in caring for foster children with fatal and incurable human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS). These children are not receiving consistent care and counseling.
Some have been enrolled in clinical trials and did not have advocates appointed for them. At least one foster facility that cared primarily for children with HIV and AIDS was closed due to poor living conditions and substandard care.
Twenty-six Texas foster children received at least one HIV medication and had at least one outpatient HIV procedure in fiscal 2004. More than 15 had at least one outpatient procedure with an HIV-related diagnosis code, but did not receive any HIV medications—a peculiar and disturbing pattern.
Many of these children were categorized at the lowest, basic service level.
In fiscal 2004, 63 foster children were raped while in care; of these, only 16 received HIV tests.
Meaning that 75 percent of those raped were not tested for HIV following the rape, as required by law.
One foster child with HIV who was also medically fragile had more than 600 outpatient claims and more than 200 prescription drug claims in fiscal 2004.
This child lived in rural Texas, in a 1,300 square-foot mobile home with four other foster children, one of whom also was medically fragile. A review of the DFPS records indicated that this small home was not licensed to care for more than four children.
Sexually Transmitted Diseases
Some Texas foster children are suffering from sexually transmitted diseases (STDs).
Many are sexually active or were sexually abused while in care, while others come into care with the disease. In fiscal 2004, more than 200 foster children were diagnosed with STDs.
Most of them were teenagers between the ages of 15 and 19. DFPS should recognize this problem and actively address it through education, testing and appropriate treatment.
The review team found irregularities in prescribing practices and counseling delivered to foster children with STDs; females in foster care were six times more likely to be diagnosed with a STD than males.
Pregnant Foster Children
In fiscal 2004, 142 foster children delivered babies. The DFPS guidelines regarding birth control, pregnancy and abortion are vague and are not given to providers and foster parents. Some pregnant foster teens received powerful psychotropic medications that are not recommended for use in pregnant women.
And many were moved repeatedly throughout their pregnancies, because many residential treatment centers and foster homes will not take them.
Some pregnant foster teens received powerful psychotropic medications that are not recommended for use in pregnant women.
Texas has few specialty maternity homes that can offer services to these teens. Foster teens and their new babies, moreover, often were not placed in the same home in a timely manner following their discharge from the hospital.
Contraceptives and Foster Children
In fiscal 2004, Medicaid spent $176,814 on more than 4,300 birth control prescriptions for more than a thousand Texas foster children. Medical claims for these children suggest that not all sexually active foster children receiving these medications were given their recommended yearly gynecology examinations.
A 15-year-old mentally retarded foster child received eight different prescriptions for birth control pills in fi scal 2004, but had no claims for a gynecological examination.
And, a 17-year-old foster child received six different prescriptions for birth control patches in fi scal 2004, but had no claims for a pap smear or gynecological exam. This child was diagnosed with a sexually transmitted disease early in fi scal 2004.
Injuries and Deaths
In fiscal 2004, 46 Texas foster children died while in care. DFPS determined that five of these deaths resulted from abuse and neglect, but 15 cases were left “open” and abuse and neglect were not ruled out. Many other foster children were taken to emergency rooms or hospitals with very severe injuries and medical conditions. Medicinal Poisonings More than 150 foster children were poisoned by medication in fiscal 2004, and not all of these cases were investigated by DFPS.
Some foster children remained in the same foster homes after they survived the poisoning.
DFPS and HHSC should ensure that every poisoning from medication is investigated.
The DFPS hotline received a report that a nine-year-old child was being overmedicated, but the agency did not investigate the case.
Foster Children and Clinical Trials.
It was revealed in May 2005 that HIV positive Texas foster children had been enrolled in experimental clinical drug trials. This news sparked nationwide coverage of the topic, since the children were being exposed to potentially serious and even lethal side effects of the trial drugs.
Because of the confidential nature of clinical trials, it is not possible to find out details regarding Texas foster children enrolled in such studies, but some questionable indicators were uncovered – such as medications were billed with no record of medication payment and foster children that are HIV positive with no Medicaid billings for medications.
Section 6544 of the DFPS Handbook states: …no HIV infected child in DFPS conservatorship may participate in any experimental drug therapy…unless the child or child’s caregiver first secures the written approval of the child’s physician or program director of the child’s conservatorship unit.
The review team asked DFPS how many foster children participated in any experimental drug therapy or clinical trials from fiscal 2004 to 2006, and how such participation is reported or tracked and if there is detail by disease or condition.
The agency responded as follows: There are currently no clinical trials for HIV, so no children in foster care were enrolled in this type of trial between FY 2004 and FY 2006. A few children in foster care may be enrolled in other clinical trials.
This response is vague and it is clear DFPS either does not know how many foster children are in clinical trials—or chooses not to tell. According to the U.S. National Institutes of Health website in September 2006, there were 1,928 clinical trials under way in Texas, including several related to HIV. Executive Summary and Systemic Recommendations
More than 150 foster children were poisoned by medication in fiscal 2004, and not all of these cases were investigated by DFPS. Foster Children: Texas Health Care Claims Study – Special Report — vii The Medications In fiscal 2004, Texas Medicaid spent $30 million for powerful, expensive psychotropic prescriptions for Texas foster children. Many of these children received multiple medications. Psychotropic medications can have very serious side-effects and their use should be strictly monitored; a large number of them are not approved for use in children or adolescents.
The review team found that Texas foster children receive more psychotropic medications than their counterparts in mid- Atlantic and midwestern states. DSHS has set voluntary parameters for the use of psychotropics by foster children. These guidelines were released in February 2005 and were supposed to be revised annually.
A committee met in August 2006 to discuss the revision; the first revised parameters were scheduled for release in October 2006. Key concerns identified by this review include: Costly Psychotropic Medications In fiscal 2004, psychotropic drugs accounted for more than 76 percent of the cost of all medications prescribed to foster children, which totaled $39 million for all medications.
All other drug categories, including a wide variety of drugs from antibiotics to cancer medications, accounted for just over 23 percent of the total or $9.2 million. Of all drugs prescribed to children in foster care, three psychotropic drug classes —antidepressants, antipsychotics and stimulants— were the most frequently prescribed.
In fiscal 2004, Texas Medicaid spent more money on antipsychotic drugs for foster children, more than $14.9 million or 38 percent of the total, than on any other class of drugs. The average cost per prescription for psychotropic drugs was $114.69. The average for all other drugs, by contrast, was $52.17 per prescription. Antipsychotics: In fiscal 2004, Texas Medicaid spent nearly $15 million on 65,469 anti-psychotic prescriptions for Texas foster children.
These very powerful and expensive medications were prescribed despite a lack of studies demonstrating their safety and efficacy in children. There are questions regarding the long-term safety of these medications; documented serious side-effects include menstrual irregularities, gynecomastia, galactorrhea, possible pituitary tumors, hyperglycemia, type 2 diabetes and liver function abnormalities.
Close monitoring of these medications by physicians is essential; Texas foster children are not receiving this attention. In addition, more than 400 foster children were prescribed antidyskinetics drugs to control side effects from antipsychotics. Side effects from antipsychotics include tremors, tics, dystonia, dyskinesia and tardive dyskinesia.
Stimulants: In fi scal 2004, Texas Medicaid spent $4.5 million on 45,318 stimulant prescriptions for more than 6,500 Texas foster children.
Nearly all of these medications are Schedule II controlled substances, due to their high potential for abuse and severe psychological or physical dependence. More than a quarter of all male foster children and nearly 15 percent of female foster children received prescriptions for stimulants in fiscal 2004; nearly 200 of these children were aged four or younger.
In addition, some foster children received many questionable high-cost, high-dose prescriptions.
One prescription for a foster child was written for 360 pills of the stimulant Adderall XR 30mg—for a 30-day supply. Yet, Adderall XR is an extended-release medication meant to be taken only once daily.
Anticonvulsants (Mood Stabilizers): accounted for more than 76 percent of the cost of all medications prescribed to foster children, which totaled $39 million for all medications.
In fiscal 2004, Texas Medicaid spent nearly $4.8 million on nearly 43,000 mood stabilizer prescriptions for about 4,500 Texas foster children.
This included 133 children aged four and younger.
These medications are used to treat bipolar disorder, anxiety and depression; some also are also used to treat seizures and epilepsy.
Trileptal and Topamax, which together accounted for about 38 percent of all mood stabilizer prescriptions, have no established efficacy for psychotropic use in either children or adults.
Antidepressants: In fiscal 2004, Texas foster children received more than 66,000 prescriptions for antidepressant medications, making this drug class the most commonly prescribed medication.
Antidepressant medications ranked fourth in the total cost of prescriptions for fiscal 2004, at $3.8 million.
In June 2003, the U.S. Food and Drug Administration (FDA) began to investigate the use of antidepressants to treat children and adolescents.
In October 2004, the FDA ordered drug manufacturers to place a “black box” warning on all classes of antidepressants stating that they may increase the risk of suicidal behavior in children and adolescents.
Anxiolytics (Anti-anxiety): In fiscal 2004, 688 foster children received 3,113 anti-anxiety prescriptions.
The largest subclass of these drugs, and the most widely prescribed, are the benzodiazepines. These drugs have been used with success to treat anxiety, but their use is limited because they have sedating side effects and may be habit-forming when taken for a long time or in high doses.
Anxiolytics are regulated under Schedule IV, by the U.S. Drug Enforcement Administration (DEA). Hypnotic/Sedatives: In fiscal 2004, Medicaid spent more than $72,000 on nearly 2,500 hypnotic/sedative prescriptions for about 1,000 Texas foster children, including 232 children aged four and younger.
These medications are used to treat anxiety or sleep disorders. They can cause dependency in just a few days and tolerance in a few weeks.
Psychotropic Use by the Very Young
In fiscal 2004, 686 foster children aged four and under received more than 4,500 prescriptions for psychotropic medications, the majority of which are not approved by the FDA for use in children.
A two year-old foster child with no diagnoses indicating psychosis received seven prescriptions for Risperdal, a powerful antipsychotic, totaling more than $700.
In fiscal 2004, Medicaid spent $4.6 million on more than 53,000 prescriptions for controlled substances for more than 9,600 Texas foster children.
The U.S. Drug Enforcement Administration (DEA) has placed these substances on the controlled substances list because of their high potential for abuse.
More than 2,300 Texas foster children, including 871 children age four and younger, received more than 3,200 prescriptions for addictive narcotic syrups.
A total of 177 foster children received more than 1,100 prescriptions for phenobarbital.
Long-term Risks and Polypharmacy
The Zito & Safer External Review notes that the widespread use of antipsychotics in children and adolescents raises particular concerns regarding long-term safety.
Serious questions exist regarding this issue, which involves documented, side effects.
Little is known about the long-term effects of early and prolonged exposure to psychotropic medications on the development of children’s brains.
These findings underline the importance of further research to determine the safety and efficacy of pediatric psychotropic drugs and polypharmacy.
The use of psychotropics in the Texas Medicaid population of children and adolescents tripled from 1996 to 2000.
A 2004 Texas study by the HHSC’s Office of the Inspector General revealed that foster children receive more psychotropic drugs on average than other Texas Medicaid children.
Psychotropic use by Texas pre-school-aged foster children was three times higher than among similar foster children in the Mid-Atlantic states. Instances of “polypharmacy,” the prescription of two or more psychotropics for one person—has increased rapidly as well.
Complex psychotropic drug therapy tends to result in ever-increasing combinations that tend to increase in continuously enrolled populations and present risks for long-term safety in developing youth.
Off -label Usage
Most psychotropic medications have not been studied extensively for efficacy and safety in children.
The National Institutes of Mental Health notes that about 80 percent of psychotropic drugs are not approved for use in children or adolescents.
Their use in this population is described as “off-label.” Yet the off-label use of these drugs in children is common.
Many medications prescribed to Texas foster children have been shown to have no or minimal efficacy. Among antidepressants, for instance, FDA findings from clinical trials showed little or no efficacy from the use of escitaloram (Lexapro), paroxetine (Paxil) and venlafaxine (Effexor).
Yet prescription patterns among foster children appears to ignore such findings from clinical trials that show a lack of or minimal efficacy. In fiscal 2004, Texas foster children received the following:
•escitaloram (Lexapro): nearly 12,000 prescriptions totaling $763,000.
• paroxetine (Paxil): more than 550 prescriptions totaling almost $50,000.
• venlafaxine (Effexor): about 3,000 prescriptions totaling more than $300,000.
Many anticonvulsant drugs are being used as mood stabilizers for Texas foster children, including oxcarbazepine and topirimate.
These drugs have been found to be ineffective for psychiatric purposes. Nevertheless, they were widely prescribed to Texas foster children in fi scal 2004:
• oxcarbazepine (Trileptal): nearly 13,000 prescriptions totaling $1.98 million.
• topiramate (Topamax): more than 3,300 prescriptions totaling more than $500,000.
Compound Drugs In fiscal 2004,572 foster children received nearly 2,000 prescriptions for compound drugs.
The FDA is concerned that such drugs carry a risk of contamination and the efficacy and potency can be effected. Fraud and abuse can also be a factor in compound drug prescriptions.
Recommendations to improve the Texas Foster Care system that should be implemented immediately:
1. The Health and Human Services Commission, Office of Inspector General should fully investigate areas of concern and cases of interest identifi ed in this report.
2. DFPS should hire a full-time physician to serve as its medical director, to oversee the care, treatment and medications provided to Texas foster children. The medical director should evaluate medical care provided to foster children and report the results to the DSHS and HHSC annually. The medical director should establish an analysis team to assist with the evaluation. The team should consist of psychopharmacologists and child and adolescent psychiatrists from medical schools.
3. The newly created DFPS medical director should be responsible for ensuring that all foster care parents and facilities receive “medical passport” information within 48 hours of the foster child’s placement. The “passport” should be updated consistently and should document all medical treatments, prescriptions, psychological diagnoses and counseling to provide continuity of care.
4. DSHS should review this report and begin implementing its recommendations as soon as possible, including those from the external review by Zito/Safer.
5. DFPS, in coordination with DSHS and HHSC, should examine the best practices of successful foster care providers to develop and implement means to reduce the system’s reliance on psychotropic medications to treat foster children.
6. DFPS should establish strict rules regarding participation by foster children in any type of clinical trial. In addition, DFPS should track and monitor all foster children who are enrolled in clinical trials. All foster parents and providers should be made aware of the rules and the potential risks of clinical trials.
Additional recommendations more specific to each problem are made in later chapters in this report. Foster Children: Texas Health Care Claims Study – Special Report
Some foster children receive counseling services, but not all do, and others do not receive consistent counseling.
According to the American Counseling Association, “Professional counselors help clients identify goals and potential solutions to problems which cause emotional turmoil; seek to improve communication and coping skills; strengthen self-esteem; and promote behavior change and optimal mental health. Counseling is a technique that can be used by individuals coping with a mental illness, recovering from a trauma, managing stress, or dealing with family issues.”
While some foster children suffer from severe mental illness, others have milder problems. The various options described below may help to reduce the number of psychotropic prescriptions prescribed to Texas foster children. Innovative Therapeutic Provider One Texas therapeutic foster care provider consciously uses a different approach to treat very troubled foster children, most of whom are classifi ed by service level as specialized.
This facility employs intensive therapeutic intervention that focuses on teaching children appropriate ways to problem-solve and make healthy and positive choices in their lives.
In an interview regarding the usage of psychotropic medications, a staff member stated that children at this facility are held accountable for their actions and are taught to manage their behavior with as few psychotropic medications as possible.
He (a staff member) also said that some children come into their program so heavily medicated that they are “drooling.’
An innovative therapeutic foster care provider has been successful in lowering the number of psychotropic medications given to foster children in its care.
Not all foster children who need counseling are receiving it on a regular basis. •
DFPS is not doing all it can to promote mentorship for foster children.
Since publication of the Comptroller’s Forgotten Children report in April 2004, the Department of Family and Protective Services (DFPS), the Health and Human Services Commission (HHSC) and the Department of State Health Services (DSHS) have been addressing psychotropic medication use by foster children.
DSHS has established medication parameters to help monitor and reduce the number of prescriptions.
Yet many psychotropic medications still are being prescribed to all ages of foster children. While medication may be beneficial in treating mental disorders, a “pill” cannot solve all of the emotional issues and problems foster children face while in care.
The Zito/Safer External Review states,
“poverty, social deprivation and unsafe environments do not necessarily require complex drug regimes.”
Often when foster children experience emotional problems they undergo psychiatric evaluations and are then taken to a physician, frequently a psychiatrist (but not always) who then prescribes one or more medications to help treat the problem.
While medication may be beneficial in treating mental disorders, a “pill” cannot solve all of the emotional issues and problems foster children face while in care.
A check of this provider’s Medicaid claims for foster children in its care showed that their usage of psychotropic medications decreased.
It is also important to analyze underlying causes that can affect mental health. Britain’s Mental Health Foundation has observed that,
“An integrated approach, recognizing the interplay of biological, psychological, social and environmental factors, is key to challenging the growing burden of mental ill-health in western nations.”2
Researchers are discovering how aspects of environment and social class can be associated with children’s poor health and behavior.3
Britain’s National Health Service has found that mental health problems are more common among people in poor living conditions, members of certain minority groups and the disabled.4
In Forgotten Children and its subsequent studies, the Comptroller’s office has found that Texas foster children often come from unhealthy living environments, and some remain in unstable and unsafe living conditions while in the foster care system. These include medically fragile children living in very small homes with many children, in mobile homes and in remote, isolated areas of the state.
Administrators at psychiatric hospitals told the review team that some children they treat have refused to return to their previous placements because they were so unhappy there.
Medical records revealed about 200 claims for scabies and multiple claims for the treatment of parasites in fiscal 2004, involving about 1,500 prescriptions at a cost of $80,000.
Scabies often is found among people living in crowded and unsanitary conditions. An unhealthy living environment can affect the mental health of already emotionally fragile children.
Alternatives to Psychotropic Medications – Psychotherapy
Psychotherapy is a common treatment that can help children understand and resolve their problems and modify their behavior. It can come in many forms, including individual, family and group therapy, play therapy and cognitive behavioral therapy.5
Many foster children need therapy because they have been removed from their homes, which can be very stressful. The Comptroller’s office has found that Texas foster children often come from unhealthy living environments, and some remain in unstable and unsafe living conditions while in the foster care system.