Experts who reviewed the inspector general’s findings note the state’s high rates of prescribing
Like all states, Indiana is required to have a plan for overseeing and coordinating the health care for any child placed in foster care, including medications they are prescribed. But this year, when a federal inspector general looked at how powerful psychiatric drugs and opioids were being delivered to a sample of children in the state, something disturbing emerged: Almost no one was keeping complete records.
In nearly 95% of 115 cases where children had been prescribed these medications for mental health disturbances or pain, the Office of the Inspector General for Health and Human Services could not find some documentation required under state policy.
The federal watchdog’s office also noted the risks, in its audit published last week: “Medications can have serious side effects, and ineffective monitoring may increase the risk for inappropriate dosing, frequent medication changes, or the use of inappropriate medication combinations.”
The poor oversight by Indiana’s Department of Child Services raised concern among medical experts, foster families and Indiana lawmakers from both political parties who were consulted by The Imprint. Yet they zeroed in on an even more alarming finding, briefly mentioned in the 21-page report, titled “Indiana Did Not Comply With Requirements for Documenting Psychotropic and Opioid Medications Prescribed for Children in Foster Care.”
Of the 18,593 children under the state’s care in 2019 and 2020, 6,334 foster kids — 34% of the total — were prescribed psychotropic or opioid medications. Of the 156,153 prescription claims submitted for these children, 99% were psychotropic medications.
The state’s prescribing rate is well above a 22% national average for state foster care systems, according to a national audit that examined 2013 data.
Less than 12% of the broader population of children — those with public or private insurance — are typically prescribed psychotropic medications, according to the University of Maryland School of Medicine professor of psychiatry and pharmacy Julie Zito, an expert in the field. That stands in stark contrast with the one-third of Indiana foster children who receive the drugs.
Indianapolis-area foster mom Allison Missler told The Imprint the audit reflected her experience. When she began taking in kids removed from their homes due to abuse and neglect allegations, she did not expect to encounter the heavy impact of powerful, mood-altering psychiatric medications. But that’s what happened in some cases after child welfare case workers began dropping off tired children with painful trauma histories at her home.
Missler said some arrived frightened, lugging unmarked, Ziplock baggies of pills without prescription bottles. Yet despite receiving nearly 80 children in her home, she said she hasn’t always received written medical information about the children’s state of health. She said she never administers medications without a current prescription bottle.
But she added the difficulty of foster parents’ circumstances.
“I should know the medication they are on, instead what often happens is I get a pill sorter, with various medications, a.m./p.m., seven days a week,” said Missler, who worked in the pharmaceutical industry for 20 years, and shared some of these details and others concerns with Indiana state lawmakers in an August hearing. “I take it upon myself to look at each one using a pill identifier on the web where you can tell by the shape and color and the stamp on the pill.”
A spokesperson for the state child welfare agency declined to respond directly to a request for comment on the new federal audit and the critical responses to its findings. Instead, she referred to a five-page letter written by the director of the Department of Child Services appended to the audit by the U.S. Health and Human Services Office of Inspector General (OIG).
Director Terry Stigdon wrote that her state “is pleased the OIG found no instances of harm or inappropriate medication distribution to any children.” She also noted “much of the information listed as missing in this audit was in fact sent to the agency’s family case managers,” and stated that “a significant technological upgrade,” to its case management systems had been underway since 2020.
Stigdon went on to note, however, that “this monitoring process has afforded our agency the opportunity to improve our record-keeping policies and practices.”
Five University of Indiana School of Medicine researchers and Indiana-based psychiatrists, including members of a Child Services’ medication advisory committee, declined or did not respond to interview requests this week.
Children in foster care typically have experienced trauma, loss and upheaval. The American Academy of Child and Adolescent Psychiatry has recommended “individualized, family-driven, and youth-guided” treatment as an “ethical and a pragmatic imperative.” But numerous authorities — from federal government health care audits to journalistic exposés — have shown state agencies stepping in as parents often fail to properly monitor the medications given to youth as they move through the foster care system.
The drugs foster children are often prescribed — antipsychotics, mood stabilizers — have not been tested on minors for their common off-label uses. Medical experts have raised concerns about dosages that are too high and multiple medications being prescribed at once, making it impossible to monitor their impacts.
The most concerning tend to be antipsychotic drugs, designed for adults with the most severe mental health diagnoses such as schizophrenia and bipolar disorder. These types of medications, while they can be soothing in the short term for a child who is out of control, are known to cause potentially devastating and lifelong side effects, including diabetes, obesity and chronic tremors and tics. They can also be heavily sedating, to the point of stupor and near-constant exhaustion.
In Indiana, according to the new federal audit, antipsychotics represented 20% of all mental health drugs prescribed to foster children in 2019 and 2020.
Dr. Martin Irwin, a clinical professor of child and adolescent psychiatry at New York University’s Grossman School of Medicine, has advised states and cities nationwide on their psychotropic policies in foster care. He cautioned that the audit doesn’t say enough about the overall quality of medical care Indiana foster youth have received. But he said its findings still raise grave concerns, particularly given the examples the IG noted in its report released last week.
In one case, for example, an 8-year-old’s Medicaid records showed 10 different psychiatric medications prescribed in a two-year span, including four different drugs in the same month.
“What astounds me, is this has to say something negative about the average practice of providers in Indiana,” said Irwin, who added that Indiana isn’t alone among states failing to track medication usage. “I have to assume they are not using a lot of psychotherapy. Because if they were, it would be hard to imagine this rate of medicine.”
In an interview, Indianapolis-area State Rep. Cherrish Pryor (D) said her relatives had taken in a young child who arrived heavily medicated. It wasn’t until a new doctor tapered some of the medications that they really got to know the child.
“We were able to see what this personality was, for this beautiful kid that we got pretty close to,” she said.
Pryor said that her state’s Department of Child Services had made improvements under its current director Stigdon, who was appointed by Gov. Eric Holcomb (R) in early 2018 after nearly two decades working in nursing at Indianapolis’ Riley Hospital for Children. Still, the new audit alarmed her.
“I was happy to see her acknowledge that there were breaks in the system,” she said of Stigdon’s response to the audit. “I was, however, quite surprised with the high number of kids that were on medication. That was a shock. I would like to see them do a real evaluation of whether all these kids are needing this medication.”
Pryor’s Republican colleague Sen. Jon Ford had similar concerns, noting that the lack of guaranteed legal representation for children in Indiana foster care — one of fewer than 10 states that does not provide lawyers for kids — leaves children even more vulnerable to poor medical advocacy.
“We are one of the few states in the country putting kids in institutions and putting them on medications without legal representation,” said Ford, who represents the Terre Haute area. “That to me is just very, very scary.”
Ford said he plans to continue pursuing legislation to address the lack of legal representation in abuse and neglect cases, as well as a separate bill he co-authored requiring an examination of the “supervision and distribution” of psychotropic medication for foster youth. “We look at that prescription rate and some of these audits, we keep appropriating more money, and we keep being told money will solve the problems, but it seems like we are going in the wrong direction,” he said.
Still, one leading advocate for foster youth, a healthy policy expert who helped push for accountability measures in California, pointed out a larger issue in Indiana’s approach to treating foster youth. While the state’s psychotropics policy notes that “alternative therapies and behavioral approaches should be explored before psychotropic medication is considered,” it also defines the drugs as “used to control and/or stabilize mood, mental status, behavior, and/or mental health.”
Anna Johnson, a director for housing and health at the San Francisco-based John Burton Advocates for Youth said the policy should state the opposite, and explicitly bar use of these medications for that purpose.
“These drugs are not supposed to control anyone’s behavior,” Johnson said.
In response to public scrutiny and changing guidance from medical societies, many states implemented new oversight protocols over the past decade. Last month, the Imprint reported the nation’s largest foster care system, in California, had decreased its psychotropic prescribing to foster youth to under 12% of the population. Those 2020 figures followed a raft of strict new protocols that included independent reviews of prescriptions from pharmacists and judges, public data-tracking and accountability measures for multiple players in the foster care system.
Indiana launched an advisory committee in 2013 that included medical experts from the University of Indiana School of Medicine, which aimed to reduce misuse of the drugs.
And its Department of Child Services (DCS) has now pledged to pursue three recommendations made by federal inspectors to improve documentation practices and oversight of medications, including new staff training and policy reviews.
But in its response to the federal audit, the agency also claimed “no children were incorrectly or unsafely prescribed medications.”
Some experts, lawmakers and foster families questioned that assertion, citing the high overall rate of medication, the 8-year-old’s case, or the findings for children in group residential facilities. For example, the feds were unable to find required 30-day and 90-day medical updates for 13 of 21 foster children residing in group settings.
Indiana officials say they will now “implement additional procedures to obtain and document” the required reports and reviews of prescribing in group facilities. But that failed to assuage some critics.
“For these kids, they didn’t even have a record they were being seen every three months — which is a horrendous standard. They should be seen every month,” said Dr. Irwin of New York University. “So even with the lowest standard imaginable, they are not meeting it. This audit is a powerful indictment of the state.”