California is one of six states that place decisions concerning psychotropic medication of foster children in the hands of the juvenile court. In 1999 the legislature, at the urging of Los Angeles County Juvenile Court Judge Terry Friedman, enacted Senate Bill 543.
The legislation took away the authority of parents whose children were placed in foster care to make decisions about whether or not their child should be given psychotropic medications.
By handing over the authority to decide if a child in foster care should be given psychotropic medication to the juvenile court, the legislature sought to reduce the growing use of medication as a means of controlling troublesome behaviors of foster children. But since the statute’s enactment the use of psychotropic medications with foster children has continued to increase steadily, which raises questions about the efficacy of the process.
During California’s Beyond the Bench XXII conference in December, about 90 professionals [attorneys, judges, social workers, etc] participated in a workshop entitled “Psychotropic Medication of Foster Children and Other Wards of the Court: Time for Change?”
Most participants agreed that juvenile court control should be continued, but called for changes aimed at improving the oversight of medications administered to foster children. The timing is right: California’s Departments of Social Services (CDSS) and Health Care Services (DHCS) have begun a Quality Improvement Project (QIP) in response to the Congressional mandate that states adopt protocols for the appropriate use and monitoring of psychotropic medications administered to children in foster care.
Below is a summary of the areas of concern and suggestions for change identified by participants during the workshop.
Comprehensive Assessment as a Prerequisite to Prescription Approval
Rules of Court require that a Prescribing Physician’s Statement must accompany the application to administer psychotropic medications but the Rule does not require the completion of a comprehensive evaluation as a condition for court’s authorization of medication.
Participants recommended that the court be provided with the results of a thorough assessment of the child’s physical, mental, and emotional health before signing off on any authorization. Completion of an assessment prior to beginning pharmacotherapy is part of the several sets of principles, parameters, and guidelines adopted by the American Academy of Child and Adolescent Psychiatry.
Improved Court Monitoring
Court orders authorizing psychotropic medications expire 180 days from the date of the order, but the rules are silent about what monitoring is to be conducted in the interim. At least one jurisdiction, Los Angeles, requires a progress report no later than 40 days after the child begins the medication.
Participants recommended that caregivers be educated about the adverse reactions to watch for, and that any adverse reaction to the medication be reported promptly to the court. If at any point between the initial order and the 180 days the court is notified that the child is suffering a significant adverse effect, the court should conduct a review.
Since some adverse reactions may not be detected without blood or lab work, courts should specify in their orders the types of periodic tests the child should receive. Examples include weight, height, heart rate, blood pressure, lipid patterns, full metabolic panels, liver function, pregnancy test and screens for other substance use.
Participants raised concerns about the qualifications and training of professionals prescribing to children in care. Although some large urban jurisdictions like Los Angeles have several mental health professionals available to review applications, in many jurisdictions access to child psychiatrists is limited and as a result general practitioners or pediatricians are prescribing psychotropic medications.
Since increasing access to psychiatrists, particularly in rural areas, is likely to be difficult, members of the group suggested making psychiatric consultants available to physicians and to the courts. Several states, Washington among them, have instituted a consultant service available statewide. California should consider establishing a similar consultant pool.
Aging-Out Youths’ Access to Care
Concern was raised for youth transitioning out of care. Often they are not connected with providers before they age out. Amendments to California law in 2013 made it clear that when a foster child reaches the age of 18 the court’s authority to authorize psychotropic medications expires. But youth who choose to continue with medication or for whom gradual reductions in medications are necessary should be able to access such treatment.
Some of the concern about loss of health care services will be alleviated under the Affordable Care Act, which guarantees Medicaid coverage for aged-out youth until age 26. Many youth, however, receive services through a program or network of providers to which they may no longer have access as adults when they exit care or are emancipated. It is critical that youth in care are supported in accessing health care, services, including psychotropic medications, upon leaving care.
Many participants mentioned the need for checklists or other tools to help guide them and judges through the court process. A one-page sheet of questions or a checklist for bench officers, judges, and attorneys was requested. During the workshop, psychologist Kevin Jervik went over a handout currently used in Los Angeles.
The handout lists a number of “red flags” that should trigger greater scrutiny of recommendation to prescribe psychotropic medications for a child in foster care. Similar tools or checklists should be made available to attorneys, caseworkers, court-appointed special advocates, and others and put into use in other jurisdictions.
Increasing Youth Voice
Rules of Court require that the Physician’s Statement in support of administering psychotropic medications must include a “statement that the child has been informed in an age-appropriate manner of the recommended course of treatment, the basis for it, and its possible results” as well as the child’s response to this explanation. Participants called for similar involvement of youth in broader policy developments at the state level.
The state’s Child Welfare Council is examining psychotropic medication issues. Participants noted the absence of youth involvement in those groups and called upon the Departments to enable youth to participate.
Improving Access to and Using Data to Guide Reforms
Data on the authorization and prescribing of psychotropic medication to children in foster care is maintained in the state’s Child Welfare Services/Case Management System (CWS/CMS) and by the Pharmacy Benefits Division of DHCS.
CWS/CMS data identifies those children for whom the juvenile court has authorized medication. Pharmacy Benefits reports those prescriptions that are actually filled and paid for by MediCal. Participants urged CDSS and DHCS to work together to provide counties with data from both systems.
Matching juvenile court authorizations with the data on actual prescriptions filled would allow counties to ensure that the juvenile court authorized the prescriptions foster children were being administered. It would also allow counties to monitor whether or not prescriptions were being filled and refilled timely, avoiding potentially dangerous gaps in medication.
Participants also urged CDSS to help counties improve the accuracy of the data entered into CWS/CMS. Sharing data regularly with the counties also could be used to set targeted goals for improvement.
The Child PsychDrug Safety Team is a division of the National Center for Youth Law.