Psychotropic Medication Monitoring for Children in Foster Care: State Approaches and Implications
Child welfare agencies currently confront a crisis regarding safe psychotropic medication use for children in foster care. Safety concerns exist with regard to specific prescribing patterns among children in foster care, including the use of second-generation antipsychotics, polypharmacy, and the use of psychotropic medications among young children. In response, the Child and Family Services Improvement and Innovation Act (P.L. 112-34) was enacted in 2011; State and tribal Title IV-B child welfare agencies were then required to collaborate with Medicaid and mental health agencies, and pediatric experts, to develop a psychotropic oversight protocol for children in foster care by June 30, 2012. Based on semi-structured qualitative interviews and survey data, this study presents a typology for psychotropic monitoring mechanisms for children in foster care.
Semi-structured qualitative interviews were conducted with 72 key informants from fifty states and the District of Columbia (hereafter ‘states’) out of a possible fifty-one (100%). The semi-structured qualitative interview was designed as an hour long telephone interview and collected information related to mechanisms for psychotropic medication monitoring for children in foster care. When the key informant held limited knowledge of a mechanism housed in another agency, a key informant from that agency was also interviewed. Based on a priori and emergent coding, a typology for monitoring mechanisms was developed. As a means of data validation, templates were completed for each of the 51 states between November 2012 and April 2013; respondents received templates, and confirmed or modified status of each monitoring mechanism.
Respondents arrived from a range of agencies, including state- and county-administered child welfare agencies (n=58), Medicaid (n=7), judicial system (n=2), and contracted academic partners or consultants (n=5). Psychotropic oversight mechanisms included 1) epidemiological descriptions of psychotropic medication rates among children in foster care, 2) voluntary consultation services regarding psychopharmacology, and 3) mandatory evaluation of whether psychotropic use complied with established safety thresholds. First, epidemiological descriptions of longitudinal and cross-sectional data pertinent to psychotropic medication use drew from databases at Medicaid, managed care organizations, child welfare information systems, inter-agency data warehouses, and contracted partners. Second, consultation services were available by phone, on-site, or by internet to prescribing pediatric and mental health providers, child welfare staff, caseworkers, and caregivers. Third, a series of psychotropic monitoring mechanisms assessed specific safety thresholds for psychotropic medication use among children in foster care and intervened, if necessary, prior to dispensing psychotropic medications (i.e., mandatory secondary opinion, prior authorization, and judicial review) or after dispensing medications (i.e., drug utilization reviews, retrospective database review, planning meetings, and administrative case reviews).
Child welfare and youth-serving partners employ a breadth of psychotropic medication monitoring mechanisms that is more diverse than what is articulated in the literature. Responses to PL 112-34 demonstrate considerable state experimentation and innovation. To leverage this experimentation, we must first establish the myriad mechanisms employed to provide psychotropic oversight across states, as described in this paper, and then examine their respective impact on access, safety, cost, and quality of mental health treatment, and ultimately, the well-being of children in foster care.