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Moderating Harmful Effects of Psychotropic Medications

(Originally published October 2019)

Last month’s commentary discussed the harmful effects of psychotropic medications on some children, adolescents and young adults, and noted the lack of research or practice guidelines available to help persons experiencing negative side effects resulting from discontinued use of these powerful drugs. I also summarized a comprehensive review of research (2016) regarding the effects of antidepressants on adolescents’ physical and mental health which notes the lack of research regarding long term side effects of these drugs, and reflects the lack of knowledge regarding the interactive effects on brain development of combining different classes of psychotropics such as stimulants, antipsychotics and antidepressants. I mentioned that some adolescents and young adults have been told by psychiatrists or other physicians that they will need to take these drugs throughout their entire lives, much as a diabetic may need to take a daily dose of insulin. This advice has a weak scientific basis (to put it mildly), especially when considering use of psychotropics targeted at mood disorders, e.g., depression, anxiety, PTSD. I encouraged readers who have contact with older adolescents in foster care or foster care alumni to talk with these young people regarding their views of psychotropic drug use on their health and mental health, and ask them whether they intend to continue taking these drugs when they leave foster care or residential care.

The potential of all classes of psychotropic drugs to harm children and adolescents has been exacerbated by questionable medical practices such as:

Using psychotropic drugs as a substitute for rather than a supplemental to mental health treatment;
Prescribing a psychotropic drug as the first response to the mental health conditions of children rather than after other non-drug therapies have failed;
Brief bi-monthly or quarterly contact with children or youth by a psychiatrist to “reup” prescriptions;
Controlling the negative side effects of one psychotropic drug with another drug (and then another to control the effects of the second drug) as described in the recent article, “The Bitter Pill,” in The New Yorker;
Prescription of a drug or drugs for which there is no evidence from clinical trials of effectiveness, e.g., use of antidepressants with children younger than age 12, or the use of tricyclic antidepressants with depressed adolescents;
The misuse (i.e., “off label” use), overuse (excessive dosage, concurrent use of two antipsychotic medications) and premature use (prior to psychosocial care) of antipsychotics (see Leckman- Westin, et al, 2018); and
Lack of medical ‘best practice’ guidelines for helping children and adolescents first reduce, and then eliminate, use of drugs possibly causing serious side effects on a child’s physical or mental health.

Caregivers, advocates, caseworkers and judicial officers have been far too accepting of the medical practices of some psychiatrists and other physicians who prescribe psychotropic drugs for children and youth, absent research regarding their effectiveness in treating a specific mental health condition, or the effects of prolonged use on children’s developing brains.

Public child welfare agencies are in the position of needing to employ or contract with one or more psychiatrists to monitor the imprudent or (actually) reckless practices of some of their professional peers. The psychiatrist(s) with the responsibility for medication monitoring has a difficult, potentially contentious, role in curbing dangerous medical practices that have developed alongside widespread use of psychotropic drugs with foster care populations.

Guidelines for Use of Psychotropic Drugs with Foster Children and Youth

The federal Administration for Children and Families (ACF) “directs states to include the following elements in their (psychotropic medication monitoring) protocols”:

comprehensive and coordinated screening, assessment, and treatment planning mechanisms to identify children’s mental health and trauma treatment needs;
shared decision making and methods for ongoing communication between the prescriber, the child, the child’s caregivers, and other stakeholders;
effective medication monitoring at both the child and agency level;
availability of mental health expertise and consultation regarding both consent and monitoring issues by a board-certified child and adolescent psychiatrist;
methods for information sharing and education related to psychotropics with clinicians, child welfare staff and consumers.

According to a 2018 report issued by the U.S. Office of the Inspector General (OIG), ACF has not established specific requirements regarding the frequency of medication monitoring or the specifics of treatment plans. Rather, “ACF has suggested that States consider practice guidelines from professional organizations (e.g., The American Academy of Child and Adolescent Psychiatry – AACP) related to treatment planning and medication monitoring …”

The OIG reviewed a sample of 625 foster children from the 5 states (not including Washington State) that had the highest utilization of psychotropic medications in their foster care populations. The states were Iowa, Maine, New Hampshire and North Dakota and Virginia. In these 5 states, 34% of children in foster care were treated with at least one psychotropic drug in FY 2013 compared to about 30% of foster children nationally. The OIG review examined whether medication monitoring and treatment planning for sampled children complied with the state’s plan.

Key findings in this OIG study include:

More than one third (34%) of foster children who were prescribed a psychotropic medication did not receive treatment planning or medication monitoring as required by agency policy.
Twenty percent of the sample did not receive adequate treatment planning, for example a mechanism for ensuring that caseworkers, foster parents and physicians were informed regarding the medications the child was taking.
In three of the five states, over half of the children who received treatment planning did not have a complete treatment plan, for example documentation of diagnoses, assessment summaries, interventions, treatment progress, information regarding possible adverse effects of the psychotropic drug(s), collaboration of a multidisciplinary team.
Almost one quarter (23%) of children did not receive medication monitoring during the study period, i.e., FY 2013.
States did not consistently incorporate professional practice guidelines in their state standards, for example “none of the five states we (OIG) reviewed included requirements to document medication dosages or potential adverse effects of medications within children’s foster care case files.”

In the OIG study, the five states with the highest usage of psychotropic drugs for foster children and youth were non-compliant with their own policies in more than a third of cases, and almost one quarter of children in the sample received no medication monitoring during FY 13, according to case files. The OIG report cautions that these findings cannot be generalized to other state child welfare systems; nevertheless, the study’s findings raise concerns that should mobilize policymakers, practitioners, advocates and stakeholders across the country. The impression created by the OIG study is of careless complacent practice related to use of psychotropics with foster children and youth; and of state systems more interested in creating an appearance of defensible standards in policy manuals than with actual implementation of protective practices “on the ground”.

Use of antipsychotics with foster children and youth

A recently published study, “Differences in Medicaid Antipsychotic Medication Measures Among Children with SSI, Foster Care, and Income-Based Aid,” by Leckman-Westin, et al, describes what occurs when public child welfare systems do a poor job of monitoring the use of psychotropic medications with foster children and youth. This study used Medicaid data for 144,200 children and adults younger than 21 years who had received antipsychotics in 10 states to calculate the prevalence of 6 quality measures for antipsychotic medication management developed by the National Collaborative for Innovation in Quality Measurement. According to the Abstract, “These measures addressed antipsychotic polypharmacy, higher than recommended doses of antipsychotics, use of psychosocial services before antipsychotic initiation, follow-up after initiation, baseline metabolic screening and ongoing metabolic monitoring.” The authors comment that “As the use of medications has increased, so has the evidence for potential adverse consequences of antipsychotic use. Antipsychotics, and second-generation antipsychotics in particular, are associated with diabetes and obesity …” thus the need for “screening for potential metabolic concerns,” a medical procedure that has been found to occur with 10-28% of patients receiving an antipsychotic drug.

Based on 2008 data, this study estimates that almost one in twenty foster children (4.4%) were prescribed an antipsychotic; 31,375 foster children were included in the study’s sample. The authors used several sources to determine whether prescribed dosages were “higher than recommended,” including recommendations of the U.S. Food and Drug Administration (FDA), guidelines developed by the Texas Department of Family and Protective Services (2013), and dosages set forth in Appendix 1 of Pediatric Pharmacology: Principles and Practice (2011).

The study tracked the percentage of children and adolescents on 2 or more antipsychotics concurrently for longer than 90 days, and the percentage of the sample “newly prescribed an antipsychotic medication and had evidence of psychosocial care 90 days before and through 30 days after starting the medication.”

Major findings from the study include:

“Compared with children eligible for income-based Medicaid, children receiving SSI or in foster care were twice as likely to receive higher-than-recommended antipsychotic doses,” (10.4% vs. 4.9%) and “multiple concurrent antipsychotics” (7.9% vs. 3.5%).“these relationships continued after controlling for age, gender, race/ethnicity, and mental health diagnosis with a primary indication for antipsychotic treatment.”
Children in foster care were more likely than other Medicaid eligible children to receive “services supporting appropriate management of antipsychotic medications and to have received a psychosocial service.” (56.8% vs. 41.5%).

3. “Just over 8% of children in foster care on antipsychotics had evidence of a baseline metabolic screen for glucose and lipid
profiles …”

Children in foster care receiving antipsychotic medication were twice as likely as children in birth families to be given excessive doses and/or to be prescribed more than one antipsychotic medication concurrently. Stated concretely, foster care was a risk factor for misuse of antipsychotic drugs, despite better medication management and higher rates of psychosocial treatment. More than 40% of foster children receiving an antipsychotic did not receive mental health treatment during the study period. The authors comment that “a large proportion of children in the absence of a diagnostic indication did not receive first line psychosocial services before beginning an antipsychotic.” Furthermore, “given the metabolic concerns associated with antipsychotic use and the fact that children may be more susceptible to the metabolic consequences of antipsychotics, screening and monitoring for both populations were disappointedly low,” according to the authors.

Implications for Child Welfare Practice

I would be surprised if the great majority of child welfare caseworkers around the country have any knowledge or readily available sources of information regarding higher than recommended doses of antipsychotics or any other class of psychotropic drugs. Hopefully, caseworkers lacking psychiatric expertise can be given access to trustworthy psychiatric consultants regarding prescribed dosages of antipsychotics, the concurrent use of more than one antipsychotic or the use of psychotropic “cocktails” that include combinations of stimulants, antidepressants and antipsychotics.

Most child welfare caseworkers already understand that every psychotropic drug has potential negative side effects, and information regarding common side effects of various classes of drugs should be delivered multiple times in training programs. Child welfare caseworkers should be trained in the interview skills needed to ask children and youth of all ages regarding side effects, depending on the child’s age and language skills, and the psychotropic drug the child is taking.

Medication management needs to include monthly, bi-weekly or (sometimes) weekly check-in with children and adolescents regarding side effects and how they experience the use of psychotropic medications. Metabolic screening of children receiving an antipsychotic medication should become routine practice.

Any treatment plan for a child taking any psychotropic medication who is not receiving non-drug mental health services should be staffed with a supervisor or with a community team. Antipsychotics and antidepressants should not be the first line of defense, or only intervention, in coping with difficult child behavior.

Most experienced caseworkers are aware that some foster parents and residential facilities occasionally insist on use of psychotropic medications to calm children, i.e., as “chemical straightjackets”, and make their behavior more manageable. There needs to be far more discussion in child welfare agencies, and with mental health therapists, and in foster parent training regarding the acceptable limits of this practice.

Summary

The misuse and overuse of psychotropic medications with foster children and adolescents during recent decades is a national disgrace. To their credit, the federal Administration for Children and Families (ACF) and most state child welfare systems have made strenuous efforts in recent years to curb dangerous practices that have become widespread in foster care systems, but this has proven to be a difficult challenge. Many states – including Washington - lack adequate child mental health services and, in the absence of these services, desperate foster parents and residential care providers have turned to psychiatrists and other physicians for the supposed expertise of biological psychiatry, and have used psychotropic drugs as a substitute for good mental health treatment.

Even the most articulate critics of biological psychiatry admit that psychotropic drugs often benefit both adults and children, especially in the short run. Strong critics of psychiatry such as Robert Whitaker and Anne Harrington do not advocate that psychiatrists and physicians stop prescribing all psychotropic drugs. Rather, Whitaker states:

“… we need to have an honest scientific discussion. We need to talk about what is truly known about the biology of mental disorders, about what the drugs actually do … If we could have that discussion, then change would surely follow. Our society would embrace and promote alternative forms of non-drug care. Physicians would prescribe the drugs in a much more limited, cautious manner. We would stop putting foster children on heavy duty cocktails and pretending it was medical care. … our social delusion about a “psychopharmacology” revolution could at last fade away, and good science could illuminate the path to a much better future.”

Somebody Say Amen.

References

Aviv, R., “The Bitter Pill,” The New Yorker, April 8, 2019.

Leckman- Westin, E., Finnerty, M, Scholle, S.H., Pritam, R., Layman, D., Kealey, E., Byron, S., Morden, E., Bilder, S., Neese-Todd, S., Horwitz, S., Hoagwood, K., Crystal, S., “Differences in Medicaid Antipsychotic Medication Measures Among Children with SSI, Foster Care, and Income-Based Aid,” Journal of Managed Care and Specialty Pharmacy, vol. 24, no.3, March 2018.

Levinson, D. Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication, Office of the Inspector General, U.S. Department of Health and Human Services, September 2018, OEI-07-15-00380.

Whitaker, R., Anatomy of An Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America (2010), Crown Publishers, New York City. ©

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