From Empiricism to Politics: Re-Visioning Medication Monitoring in Treatment for Traumatized Youth

Background: In 2011, the Child and Family Services Improvement and Innovation Act required that states develop systems of oversight to ensure “the appropriate use and monitoring of psychotropic medications” among youth in foster care. Monitoring is conceived of as a set of empirical practices through which prescribers gather information about the effects of medications on youth. However, there is limited research on how medication monitoring occurs in everyday practice. This paper analyzes the policy discourse surrounding the monitoring of psychotropic drugs in foster care to draw out key assumptions regarding the nature and sources of knowledge about the effects of psychotropic drugs in treatment settings. It then uses ethnographic data to illustrate how knowledge about medication effects is produced, circulated, and brought to bear on treatment decisions in residential care.

Methods: 18 months of ethnographic fieldwork, interviews and archival research were conducted at two sites. The first site is a state-run program designed to oversee prescribing practices in a mid-west state. The second site is a 30-bed residential center for traumatized youth aged 7 to 14 in state custody. The researcher conducted observations and interviews with staff at the first site and medical personnel, youth, case managers, therapists, administrators, and residential counselors at the second site (n=50). Specific sources include psychiatric consultations, medication passes, weekly treatment team meetings, and quarterly and monthly staffings, which were audio-recorded, transcribed and inductively analyzed. Archival sources, such as policy texts, professional training materials, and bureaucratic documents were also collected and coded. The researcher obtained IRB approvals as well as informed consent and assent from youth and professionals.

Results: The policy discourse surrounding medication monitoring in foster care makes two key assumptions: (1) monitoring can and should be an empirical process of observing, documenting, and rationally communicating about the effects of medications and (2) medication effects are objective phenomena that are either visible to the untrained eye or detectable through medical technologies or expert assessment. In practice, monitoring is not only or even primarily a process of observing objective drug effects. It is a process through which a network of actors, each of whom bears different kinds of information about the child and the medications they are prescribed, speculates about the link between medication changes and behavioral outcomes. As this process unfolds, participants have varying degrees of power to decide what role medications can and should play in a child’s treatment. This paper illustrates how different actors use the technical and communicative tools at their disposal to weigh in on medication decisions. It concludes that monitoring is as political as it is empirical.

Implications: Current policy discourse surrounding medication monitoring is oriented around facilitating an empirical process of systematic observations and rational communication. However, participants in medication monitoring have unequal stakes and varying degrees of power and voice in treatment decisions. As policymakers continue to develop systems of oversight, it is essential to establish mechanisms through which to support those involved in medication monitoring in addressing and resolving ethical and epistemic tensions as they arise.