Nearly 30 percent of foster children in Maine who were prescribed powerful psychiatric drugs did not receive a basic “treatment plan” or regular reviews of their medications, a federal investigation has found.
Just shy of one-third of children in foster care in Maine during the period reviewed by federal investigators were prescribed anti-depressants, drugs to treat anxiety and attention deficit/hyperactivity disorders or other “psychotropic” medications. The proportion of Maine foster children receiving such drugs — 1,155 of the 3,527 children in foster care, or 32.7 percent — was well above the 22.2 percent national average for the analyzed period, ranking Maine fifth behind North Dakota, Virginia, New Hampshire and Iowa.
The new report from the Office of the Inspector General of the U.S. Department of Health and Human Services raises concerns that medicated foster children in those top-five states may not be receiving adequate oversight and monitoring.
The watchdog agency reviewed the treatment details of 125 children in each of the top-five states to determine whether the states were complying with their policies as well as federal requirements. The report found that 34 percent of the 625 children did not receive either treatment planning or medication monitoring during the six-month period that was analyzed.
Additionally, 8 percent of children across the five states received neither a treatment plan nor medication monitoring, leaving them vulnerable to improper or inadequate treatment.
“The big takeaway here is there are safeguards — particularly treatment plans and prescription monitoring — that are lacking” in Maine and the four other states, said Ann Maxwell, assistant inspector general with the federal Department of Health and Human Services. “Without these safeguards, children are at a greater risk of two potential outcomes: not getting the medication they need to cope with illnesses such as ADHD, depression or anxiety … and they are also at risk of getting prescribed drugs that they do not need. And these powerful drugs can have serious side effects.”
It was unclear why foster children in Maine are more likely to be prescribed mood-altering drugs than their counterparts nationally. Officials with the Maine Department of Health and Human Services did not respond to requests for comment on the federal report Monday.
Maine performed worse than the other four states in some areas but better in others. For instance:
• Only Iowa had a higher proportion (30 percent) of foster children who did not receive a treatment plan, which lays out medical justifications for drug treatment as well as dosages, expected outcomes, etc.
• In 26 percent of the Maine cases, the treatment providers failed to follow-up on the medication plans every three months as state policy requires.
• But 89 percent of foster children on psychotropic drugs in Maine had their medications monitored by a doctor or prescribing professional, which is required. That placed Maine in the middle of the five states, led by North Dakota at 98.3 percent compliance with New Hampshire reporting the lowest medication-monitoring rate of 78.2 percent.
The Inspector General’s report noted that up to 80 percent of children in foster care enter the system “with significant mental health needs” after being separated from their families. But they also are at even greater risk of improper treatment, overmedication or other “complications.” That’s because, unlike children from intact families, foster children often lack a person or group of people able to consistently oversee their mental health treatment, especially if they change foster homes or physicians.
As a result, health information about foster children is often incomplete or spread across multiple sources such as caseworkers, foster parents and potentially different doctors’ offices. These complicating factors underscore the importance of detailed treatment plans, regular medication monitoring and routine follow-up care, the report’s authors said.
“In this population, the paperwork becomes a critical link between all of these parties responsible for making sure the child is safe,” Maxwell said in an interview with the Press Herald.
The Inspector General highlighted two particular cases of unnamed children who they said illustrated the importance of those safeguards.
In one case, a 6-year-old foster child was prescribed four different psychotropic drugs after being diagnosed with ADHD and learning disabilities, as well as behavioral, speech, hair-pulling and post-traumatic stress disorders, a tic disorder and a speech disorder. A subsequent medical review raised concerns about the suite of drugs as well as some of the dosages, eventually resulting in the elimination of two of the drugs and adjustments to others.
In the second case, an 11-year-old was prescribed two medications to address several conditions, including a conduct disorder, ADHD and anxiety. But the foster mother struggled to obtain refills for three months because two prescribing professionals said the child needed to be seen by a psychiatrist before the refills could be distributed. By the time the child was able to see a psychiatrist, the child had “lost the ability to maintain normal psychological function” and regressed the point that he or she was stealing, bullying, lying and had been the subject of an in-school suspension.
Maxwell declined to identify the states where the cases occurred, saying her office feared the specificity of the children’s cases could allow them to be identified.
“In this state, there is no requirement for caseworkers to follow up with foster parents about medication and the child’s outcomes, or assess the risk for medication nonadherence,” the report states. “The child was without prescribed medication for a time and experienced adverse effects. There was no evidence in the case file that the caseworker was aware of the nonadherence and the impact on the child’s outcome.”
The Inspector General’s report makes several recommendations, including that U.S. Department of Health and Human Services work with states to ensure they are following their own policies, potentially including “accountability measures” for failing to comply; strengthen annual reviews of state programs; and assist states in strengthening oversight programs in part by incorporating guidelines for training plans and medication monitoring such as those developed by the American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics.