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Delaware State News: Drugs in foster care scrutinized

Carper helps leads charge in identifying areas of abuse in Medicare system

Dec 12 2011

DOVER — When Ke’onte Cook entered the foster care system in Texas at the age of 4, he was almost immediately prescribed a slew of psychotropic, or anti-psychotic, drugs.

In the next seven years, he would be prescribed 20 medications altogether and up to five of the drugs at a time. The drugs were intended to treat individuals with bipolar or seizures, ADHD and other conditions Ke’onte was never diagnosed with.

“These seemed way too much for a regular kid, which I am,” Ke’onte, now 12, told Sen. Thomas R. Carper, D-Del, and other members of the subcommittee on Federal Financial Management, Government Information, Federal Services and International Security during a Dec. 1 hearing in Washington.

Sen. Carper and other members of the subcommittee had asked the Government Accountability Office (GAO) about a year ago to begin looking into Medicare to identify areas of abuse, specifically involving controlled substances like Oxycodone.

During that investigation, the GAO discovered that thousands of foster children across the country on Medicaid were being overprescribed psychotropic drugs.

Sen. Carper, who chairs the subcommittee, then called for a complete investigation into the issue by the GAO. Their report was released Dec. 1.

It found that of the 100,000 foster chil¬dren surveyed in fi ve states (Florida, Mas¬sachusetts, Texas, Michigan and Oregon), nearly one-third of them were prescribed at least one psychotropic drug.

The GAO also found that foster chil¬dren were prescribed psychotropic drugs at rates up to nearly five times higher than non-foster children. The powerful drugs were sometimes prescribed to infants un-der the age of one.

“The GAO report confirmed some of our worst suspicions regarding the prescribing of these mind-altering drugs for foster care children,” Sen. Carper said.

As for the amount of taxpayer dollars used through Medicaid to pay for the pre¬scribed drugs, in the fi ve states the GAO looked at, $375 million dollars were spent on psychiatric drugs in 2008.

Probably most revealing about the study is the fact that most states’ monitoring pro¬grams for psychotropic drugs fall short of what is recommended by the American Academy of Child and Adolescent Psychia¬try (AACAP).

The GAO recommended that the na¬tional Department of Health and Human Services (HHS) consider endorsing guid¬ance for states on best practices for over¬seeing psychotropic prescriptions for fos¬ter children. HHS agreed with the offi ce’s recommendation and sent a letter to all state health departments the day before Thanksgiving regarding the effective use of psychotropic medications among children in foster care.

“The Department of Health and Human Services has written to all the states indicat¬ing that this issue has been raised and we need to do something about it collectively across the country,” Sen. Carper said.

A doctor’s view

While legislators and state and federal offi cials react to the GAO report with frus¬tration and disgust, Dr. Barry Goldstein, a practicing child psychiatrist in Dover, said he’s had a different reaction than others not in the medical fi eld to the study.

“I got defensive as a child psychiatrist,” he said.

Those who read the report shouldn’t jump to conclusions about the dangers of prescribing psychotropic medications for children, Dr. Goldstein said.

“There are certain circumstances where these kids are very aggressive or very self destructive and they have gotten kicked out of foster family after foster family, day care after day care and clearly you have to do something to give them an opportunity to have a somewhat normal life,” he said.

Dr. Goldstein said he has worked with patients who do best when taking several medications at a time, but throughout the medical treatment of that child he is con¬stantly asking himself what is and is not necessary for their well-being.

“I will work with some kids with very serious mental health problems and they might be on three or four different medica¬tions, but my attitude is always, what can we then take off? Are we sure that we need to add another one? Because I get nervous and uncomfortable prescribing too many medications to little kids,” he said.

Before prescribing any anti-psychotic drug to a child Dr. Goldstein said he does a full evaluation involving not just the child but their parents, teachers, day care provid¬ers and any other individuals who spend signifi cant time with them.

This allows Dr. Goldstein to gain a sense of the child’s behavior throughout the day and not just at one time.

“As you start gathering that type of in¬formation what you’re trying to do is get a sense of is this just a behavioral problem where they need family counseling or is it a really more serious problem that requires medication?” he said.

If medication is found to be the best route to take with that child, the doctor must make a commitment to follow up with the patient throughout the time they’re taking the drug, especially when a child is taking more than one at a time.

“What you’re always doing is you’re go¬ing back and saying, should we really be doing this or should we be maybe taking them off the fi rst medication and trying something different,” said Dr. Goldstein. “ You really have to have people who have a lot of experience in doing this and who are always in the back of their minds saying to themselves, ‘I have to make sure above all else to do no harm to this child.’” This should involve check-up appoint¬ments every couple of weeks or at the very least once a month to ensure the medica¬tion is benefi tting the child, Dr. Goldstein said.

“If we’re keeping someone on the med¬ication we’re doing it for a good reason. We’re doing it because there really is a benefit,” he said. “This is the type of oversight and supervision that you should be doing any time you’re giving anybody medica¬tions, but especially when it’s young chil¬dren.”

One issue that does exist within the cur¬rent system is the lack of psychiatrists, Dr. Goldstein said. This means that when chil¬dren are prescribed medications, like pow¬erful psychotropic drugs, it is often done by another doctor, such as a primary care physician or someone else who is not an expert in the fi eld of psychiatry.

“The vast majority of medications pre¬scribed for children are not prescribed by board-certifi ed child and adolescent psy¬chiatrists because there’s just not enough of us to go around,” Dr. Goldstein said. “If Congress is looking at foster kids and some of them are overmedicated, one of the questions I would have is who’s prescrib¬ing their medications?”

This oversight is what the GAO found to be missing within the five states’ foster chil¬dren programs.

Dr. Goldstein said a positive effect of the report could be that doctors prescribing these powerful medications are reminded to follow the AACAP guidelines.

“There may be some practitioners out there who really aren’t being careful with giving meds to kids,” he said. “Maybe it’s good that a study like this comes out just as a reminder to say to people, be careful about how you prescribe medications to kids. Kids depend on the adults in their life to be their advocates. They can’t advocate for themselves.”

Placing blame on the doctors involved might also not be the appropriate action to take, said Dr. Goldstein, especially given that many foster care children experience horrible situations of abuse or neglect sometimes long before they come in con¬tact with doctors prescribing medication for them.

“For someone responsible like me who is working hard and trying to do the right thing and having someone come along and look over your shoulder, what I’m thinking is, how did we allow a situation to exist where a young child has been exposed to such horrible situations?”

Instead of focusing on the doctors who have prescribed the medications to the foster children, Dr. Goldstein said officials should focus instead on improving the overall foster care system so that children are no longer placed in these situations.

“When people are pointing fi ngers at the doctors saying, ‘are you prescribing too many medications?,’ I’m thinking, how did society allow all of this stuff to happen to the poor child?” he said.

“I’m trying to help them out here, but let’s be fair about who’s responsible for what and how things got to the point that they did.”

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