Drugging Children in Missouri Foster Care

The high rates of psychotropic medication use in the Medicaid population, risks associated with these drugs, and research documenting inappropriate prescribing, have raised concerns, especially for children involved in the child welfare system.

Studies suggest that appropriate prescribing practices, that is, adhering to FDA-approved use and accepted clinical guidelines, may not always be followed for certain Medicaid populations such as the high-risk populations of children in foster care. In actual fact, multiple studies and reports have found that children in foster care are vulnerable to inappropriate or excessive drug use. Children in foster care are often prescribed more than one psychotropic drug at the same time. A review in Missouri once found some children in foster care prescribed five or more psychotropic drugs.

Missouri Foster Care serves individuals age 0 to 21; not all states provide care to age 21. In FY2014 Missouri extended Medicaid benefits up to age 26 for individuals who have aged out of foster care.

In Fiscal Year 2015, Department of Social Services MO Healthnet (Medicaid) spent $1,254,900,000 for pharmacy services for 883,672 people, approximately 60% of whom were children. There were an average of 13,033 children monthly in Foster Care (19,429 individuals for the year.) The total 2015 state population of children under 18 was 1,399,075.

(Data is primarily from the Missouri Department of Social Services and Child Division reports available on the state website dss.mo.gov, as well as various Medicaid-related publications, and sites such as the Medicaid Statistical Information System.)

Average number of MO Children in Foster Care per month by Fiscal Year:

You can see that over the last four years, Missouri has been experiencing an increase in the Foster Care population, which in 2015 was the highest in the previous 12 years; indicating at the very least unmanageable caseloads.

The average age of a child in Missouri Foster Care is 10 years old, and spends an average of 24 months in foster care.

In 2014, for example, there were 7,259 Children entering or reentering state custody. There were 24,388 children, in or out of foster care, who were receiving public mental health services (meaning they were likely on one or more psychotropic drugs.)

For 2008, Medicaid Pharmacy Benefit statistics for Missouri from the Centers for Medicare & Medicaid Services show 122,274 children 5 years of age or younger; 121,095 ages 6 to 14; and 54,645 ages 15 to 20. This includes children in foster care. The top drug group for all these prescriptions in terms of cost was antipsychotics.

Missouri consistently ranks nationally in the bottom one-third of overall health status as compared to other states. Nationally, about 14 percent of Medicaid beneficiaries used a psychotropic medication during calendar year 2011. In 2011, Medicaid spent about $8 billion in fee for service for psychotropic medications—30 percent of the program’s total fee-for-service drug spending.

Some General Observations from the Data
1. Top costs are for ADHD drugs and Antipsychotics for all ages.
2. ADHD drug costs appear to be increasing year over year.
3. Babies less than a year old are more commonly given Barbiturates, one presumes as a remedy for insomnia. Barbiturates are highly dangerous because of the small difference between a normal dose and an overdose.
4. Total foster care drug costs have averaged roughly $16 Million per year, with a total for the five years 2010-2014 over $81 Million.

Drug Classes given to children in Missouri foster care (ask us for a copy of the full report):
ADHD
Antianxiety
AntidepressantAntipsychotic_Combo
Antidepressants_MAOIs
Antidepressants_SSRIsAndSimilar
Antidepressants_Tricyclics
Antipsychotics_FirstGeneration
Antipsychotics_SecondGeneration
Barbiturates
Bipolar Disorder
InsomniaNarcolepsySleepDisorders

Recommendations / Model Legislation
§ As an example, there are currently close to 63,000 children and youth in California’s Child Welfare System. Refer to this model legislation from California:
California Assembly Bill AB-1067
http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201520160AB1067
Approved by the Governor 09/30/16.
Requires the Department of Social Services (DSS) to convene a working group to develop standardized information about the rights of all minors and nonminors in foster care, and expands requirements regarding the distribution of information regarding these rights.

§ As another example, see this draft copy of suggested California legislation to expand the rights of children in foster care regarding the use of psychotropic drugs:
http://www.cchrstl.org/documents/Draft%20CA%20Foster%20Care%20Bill.pdf
A bill to amend the existing Foster Child Bill of Rights (WIC 16001.9) to strengthen the rights of foster children to participate in any decision to require mental health treatment and psychotropic medication. The state of California finds that Foster Children are subjected to excessive diagnosis and treatment by psychotropic medications, and hereby amends the Foster Child Bill of Rights to include the following additional protections for children under the care of Child Protective Services.
Section 16001.9 (a) 5 of the Welfare and Institutions Code is amended to read:
(5) (a) To be free of the administration of medication or chemical substances unless authorized by physician,
(b) To be informed of the risks and benefits of psychotropic medication in an age appropriate manner,
(c) To tell their doctor that they disagree with any recommendation to prescribe psychotropic medication,
(d) To go to the judge with an advocate of their choice and state that they object to any recommendation to prescribe psychotropic medication,
(e) To refuse the administration of psychotropic or other medication unless immediately necessary for the preservation of life or the prevention of serious bodily harm,
(f) To refuse the off-label prescription of psychotropic drugs and at-risk polypharmacy,
(g) To have prescribing doctors disclose any financial ties they have to pharmaceutical companies in writing in an age appropriate manner.

§ Go here to download more information about drugging foster care children:
http://www.cchrstl.org/documents/facts_about_foster_care_children.pdf