Colorado lags other states that established policies years ago to reduce the use of powerful psychotropic drugs by children in foster care. Since 1992, Illinois has contracted with a medical school to review all prescriptions for children in foster care and to advise state officials on whether to allow the medication.
Connecticut, Tennessee and Oregon have put similar programs in place. Each state maintains databases that track psychotropic use by children in foster care.
In contrast, Colorado officials last year acknowledged in documents filed with a federal oversight agency that Colorado’s child protection workers have no way of monitoring psychotropics given to foster children. That puts Colorado among a minority of states without such tracking.
An investigation by The Denver Post found that Colorado officials responded slowly to rising rates of psychotropic prescriptions that they knew about as early as 2007.
Of the state’s nearly 16,800 foster children, about 4,300 were on psychotropics in 2012, and 1,900 of those were on antipsychotics, their most potent form, according to figures from the University of Colorado.
Foster children in Colorado were prescribed antipsychotics at a rate 12 times higher than other kids on Medicaid, and research has found that rates of high-dosage and multidrug prescriptions in Colorado are elevated compared with a sample of eight other states.
In their federal filing, Colorado officials acknowledged the state’s automated child-welfare tracking system doesn’t follow prescriptions of the drugs to foster children, and “therefore, the information is often missing or inaccurate.”
A task force is discussing ways to monitor prescriptions to foster children, perhaps by having the state’s Medicaid program provide psychotropic drug data to the child protection system. But state officials recently said they still are trying to identify resources to develop an automated data-sharing system.
A survey of child protection systems in 47 states conducted by researchers with Tufts University in 2010 found that only 13 didn’t track such prescriptions to foster children.
Kathy Wells, medical director of the Denver Family Crisis Center and part of the state task force, considers Colorado’s approach “mindful and thoughtful and not knee-jerk” compared with states that have stopped authorizing prescriptions unless they are reviewed by a specific gatekeeper. Wells believes such a practice could harm children.
Wells said she has heard good examples from other states but does not believe any have “got it handled.”
“Even though I am a person who wants this done yesterday, it’s not that easy,” she said. “If you do this too quickly, you are potentially causing more harm than good.”
The Illinois approach
Monitoring psychotropic prescriptions in foster children can save lives, said Dr. Michael Naylor, an associate professor of psychiatry at the University of Illinois at Chicago School of Medicine who leads the Illinois program.
Naylor said he recently was surprised to see a 13-year-old’s physician prescribing maximum doses of a powerful antipsychotic and an antidepressant, which provided prolonged electrical conduction to the child’s heart. The doctor wanted to increase the dosage to the child even though the child’s heart hadn’t been monitored for years, Naylor recalled.
He required the doctor to provide an electrocardiogram, which ended up showing the “the kid’s electrical activity was bordering on potentially lethal in terms of arrhythmia.”
“If we hadn’t dealt with that in a prospective way, we would have been dealing with a death case instead of a consent,” Naylor said.
Naylor has broad powers to recommend to Illinois child protection officials whether they should approve, deny or change a medication or dosing. He can recommend that a prescription be stopped if a doctor isn’t properly monitoring the medication for metabolic effects on the child.
In Illinois, a health care provider must seek renewed approval every six months for a prescription the state has approved for a child in foster care.
Naylor also can show up at a doctor’s office to ask detailed questions when a prescription request seems unsound, which he said often causes a doctor to withdraw a medication request.
“Our program can review medical records,” Naylor said. “We can talk to doctors. On occasions, I will go out. And when I do, it’s like having people from CBS News from ’60 Minutes’ come by. It usually means something not so good.”
His work helped decrease the number of foster children in Illinois prescribed multiple antipsychotics by more than 50 percent from 2007 to 2013.
“We used to routinely see medications requests of eight, nine medications, and now those are so uncommon because they know those aren’t going to fly,” Naylor said.
The monitoring program costs Illinois about $1 million a year.
Just because the federal Food and Drug Administration has approved a drug for use by children and adolescents doesn’t mean Naylor will sign off on such a use for a foster child in Illinois. Rather, he refers to the studies and drug trials that are conducted and reviews the data to see what works and what doesn’t.
He said drug companies often push for FDA approval for newer drugs in children to increase profits and to replace a drug whose patent has expired.
“When you figure what the FDA labeling really means, it becomes clear that to use FDA labels to determine what should and should not be used is ridiculous,” he said. “Lithium is approved for use in kids, but there are no double-blind placebo studies to show it is effective.”
Standards of monitoring
Other states are ahead of Colorado in crucial areas.
In Connecticut, teams of advanced-practice registered nurses and child psychiatrists review all psychotropic prescriptions for children in foster care before approval is granted.
In addition, Connecticut maintains data on foster children who experience adverse reactions to psychotropic drugs. That information is collected and reviewed to identify patterns. The state forwards the data to federal regulators and drug manufacturers for their review.
Oregon passed legislation that became effective in 2010 that requires an annual review when a psychotropic is prescribed to a foster child under the age of 6. The state requires an annual review when a foster child of any age is taking more than two psychotropics at once.
Tennessee requires biological parents, adoptive parents or a legal guardian to give consent before psychotropics are administered to a foster child. When consent can’t be obtained or the parental rights have been terminated, a team of nurses reviews psychotropic prescriptions to determine what is medically necessary.
“Children in foster care are a very unique, vulnerable population,” said Dr. Deborah Gatlin, director of the department of medical services for the Department of Children Services in Tennessee.
In Colorado, child protection workers are responsible for determining who has the legal right to consent for treatment of foster children with psychotropics.
But Colorado officials said they don’t monitor whether those workers, who are employed by counties, are reaching out to a child’s parents or legal guardian to ensure proper consent is granted.
State officials are exploring potential reforms that would lift the responsibility from caseworkers and improve tracking of psychotropic use by foster children.
“Most caseworkers are not trained medical professionals, so asking them to decipher and enter medical information may not be the best way to achieve the best results,” said Dan Drayer, a spokesman for the Colorado Department of Human Services. “We want the appropriate people to enter the data and the best system for tracking it.”
Yet, for now, even consent forms differ from county to county.
“When treating children from multiple counties, prescribers may see multiple consent forms,” Colorado’s human services department said in the filing last year with the Administration for Children and Families, an agency within the U.S. Department of Health and Human Services that oversees child protection systems.
“Often times, these consent forms are not consistent and so do not capture all relevant information, such as what the medication is intended to treat, what benefits can be expected and what side effects to look for,” the state said.
In the filing, officials said they had come up with a template for psychotropic consent they suggest all county child welfare agencies should start using. But they told The Post they still didn’t know how many county agencies had actually put those templates in use.
With Colorado’s child protection system still struggling to come up with policies that address psychotropic use by foster children, the state agency that runs Medicaid has started to take the lead.
Last year, that agency, the Department of Health Care Policy and Financing, took the first step in regulating the use of newer-generation antipsychotics in children under 18 whose health care is paid by Medicaid. The change requires prior authorization for antipsychotic prescriptions for Medicaid beneficiaries under 18 for uses never approved by the FDA.
The department in 2010 required such prior authorization for any antipsychotic use in a child under the age of 5.
But other states acted earlier. In 2006, California Medicaid officials required prior authorization for antipsychotic prescriptions to those younger than 6.
Florida Medicaid officials required similar authorization in 2008.
Arkansas Medicaid officials in 2011 required that providers writing oral antipsychotic prescriptions for Medicaid beneficiaries under 18 submit an informed-consent form signed by the patient’s parent or guardian and a baseline metabolic lab result. As of June 2012, ongoing antipsychotic prescriptions for Medicaid beneficiaries in Arkansas require follow-up lab monitoring at least every nine months.
“We know these medications have some untoward side effects,” said Dr. Laurence Miller, senior psychiatrist in the Arkansas Medicaid program. “There is a metabolic syndrome, and we really want our physicians to remember those kinds of things. They think they’re just giving a little bit of medication, but we don’t know the long-term effects, and we know there are some short-term effects. We want to be sure they are monitoring those very closely.”
Christopher N. Osher: 303-954-1747, cosher@denverpost.com or twitter.com/chrisosher
About the drugs
Psychotropics: A broad class of medications made of chemicals that alter brain function, including mood and behavior; these include antidepressants, anti-anxiety drugs and attention-deficit-disorder drugs.
Antipsychotics: The most powerful drugs in the broader class of psychotropics; have been linked to diabetes and weight gain in children, and growth of breasts in boys.
Atypicals: The latest generation of antipsychotic medications, with brand names such as Abilify, Zyprexa and Risperdal.
About the series
This investigation by The Denver Post into psychotropic drug use by foster children stems from The Post’s “Failed to Death” series on Colorado’s child-welfare system that ran in 2012.
The overprescription of powerful psychotropic medication to foster children is a national epidemic — yet in Colorado, efforts to curb the problem lag some states.
The Post obtained unpublished state data and reports, interviewed foster families and children, reviewed other states’ efforts and examined promising new therapies.
Sunday: Foster kids are prescribed powerful drugs that alter brain function at rates far higher than other children. A growing number of experts say this is not only unnecessary, but harmful.
Monday: Over decades, the pharmaceutical industry pushed aggressively to market psychotropics to children and tap into the lucrative Medicaid system.
Tuesday: New therapies to repair developmental delays in children’s brains caused by abuse and neglect are taking hold. Proponents advocate for more therapy and fewer medications.
Wednesday: Other states have been more aggressive and more effective than Colorado in establishing policies to reduce prescriptions of psychotropics to foster children.
