Foster Kids need Services, not more Prescriptions!

New light has been shed recently on the plight of foster youth and too limited application of individualized, clinically assessed psychosocial treatment protocols for these vulnerable youth. While the national child advocacy community and certain leaders on Capitol Hill have been concerned about the over-prescribing and/or inappropriate prescribing of psychotropic medications for foster youth for some time, this conundrum has now been brought front-and-center.  The December edition of Pediatrics, the professional journal of the American Academy of Pediatrics, published a study of foster youth in one mid-Atlantic state demonstrating the high rate of prescribing of powerful antipsychotic medications for this population. Quickly following, the GAO(Government Accountability Office) published a report with similar utilization rates in five other states. Time Magazine, the New York Times, and most impressively, Diane Sawyer (ABC, 20/20) claimed the public stage to inform America about this crisis among foster youth. In short, foster youth are disproportionately being treated with major antipsychotic drugs instead of the psychosocial, behaviorally tested, evidence -informed clinical treatments that can address and ameliorate their trauma, destructive behaviors, and mental or emotional illnesses. Trauma and behavioral health issues do frequently follow the experiences of abused and neglected youth who are removed from their families for their own protection and well-being.  Ironically, a system that medicates and does not treat the underlying clinical issues might itself be accused of ‘neglect’?

Beyond the moral question of providing known, effective clinical response to foster youth, there is also a matter of cost and prudent investment of Medicaid dollars and other taxpayer monies.  The most frequently prescribed psychotropic medications are Resperdal, Seroquel, and Zyprexa. Responsible medical practitioners know that these drugs are for 1- adults and 2- for treatment of schizophrenia and bi-polar disorders, both of which are rare in the child/adolescent population. What has not been sufficiently stated in this debate thus far is the additional fact that these drugs are among the most expensive of all drugs for mental health treatment. They are expensive, they are not appropriate for the child population, and they do not address the causes of the emotional and development disabilities of foster youth to whom they are prescribed.

The Foster Family-based Treatment Association (the only national association of providers of TFC in North America) is actively engaged in solutions to better serve high-needs foster youth through treatment services. Treatment or Therapeutic Foster Care (TFC) is specialized foster care consisting of intensive behavioral health services delivered in foster homes by licensed mental health clinicians and supported 24/7 by the active participation of highly trained foster parents in the overall clinical plan for high-needs foster youth. TFC is proven to be an effective treatment for children with complex emotional, mental, and physical problems and emphasizes the delivery of clinical services.

FFTA and a broad coalition of 55 child advocacy organizations are urging CMS to publish official guidance promptly to State Medicaid Directors clearly identifying the services integral to TFC and to which custody youth are entitled under EPSDT.  The variations across states in their lack of understanding about TFC covered services too often denies foster youth access to services and forces well-meaning physicians to rely on their other ‘tool’, ie. Medication.

If utilized appropriately by state child welfare entities and state Medicaid administering bodies, TFC is a successfully demonstrated service for addressing the unique and complex trauma and behavior health challenges of foster youth who are otherwise unfortunately medicated with expensive and inappropriate psychotropic drugs.

Work to do for Child Advocates in Home States

I have been encouraging child advocate leaders in each state to monitor and become involved in the work of their own state’s development of the new “health care exchanges”, which  the Affordable Care Act requires of all states beginning 2014. Simultaneously, my work nationally with the Foster Family-based Treatment Association has included my participation as part of a national child advocacy coalition working with the Center for Medicare and Medicaid Services (CMS) as they study development of an Essential Benefits Package (EBP). We have advocated strongly for needs of foster youth to be addressed by CMS in the benefits package, including both biomedical health needs and behavioral health. 

Friday Dec. 16, HHS published ‘guidance’ announcing a framework of benchmarks each state will be allowed to consider in developing their own EBP. This does not give the federal protections we were seeking with our efforts. Instead, it requires that child advocates must actively engage with legislative, state insurance department personnel, and Medicaid administering bodies with the focus of bringing representation for impoverished and/or custody youth into the discussions.

We will continue our work nationally. You are encouraged to identify those leaders in your state who have responsibility for establishing your state exchange and developing the Essential Benefits Package. That work is well underway now. Your investment of time and energy early in the New Year is encouraged.