Experts say the ACLU’s lawsuit has overshot the systemic problems plaguing the custody system.
A lawsuit filed this week accused the two Maryland agencies that operate the foster care system of overusing psychiatric medications as a form of “chemical restraint” for some children with severe behavioral health problems without providing adequate supervision. Experts said it was a move that could highlight the growing reliance on drugs with a burdened system lacking other options.
A federal lawsuit filed against the Maryland Department of Human Services and its Department of Social Services says more than a third of all foster children in Maryland are prescribed at least one psychotropic substance. This class of medications includes antidepressants, antipsychotics, and stimulants for ADHD, among others, which are used to treat behavioral health conditions. The suit states that more than half of these children are taking more than one such drug.
Antipsychotic medications — the updated, professionally accepted term for a class of medications referred to as antipsychotics in the lawsuit — should be used with caution in children and tend to be overused, said Dr. Louis Krause, professor and director of the division of child and adolescent psychiatry at Rush University Medical Center in Chicago. among foster children.
The drugs have sedative properties and can cause side effects such as weight gain, diabetes, movement disorders and cognitive slowing.
Foster children are more likely to “act out” and exhibit behavioral problems than other children, Krause said, due to a variety of factors such as past trauma, instability in their environment, and mental health issues such as ADHD, anxiety, and mood disorders. Antipsychotics are prescribed “off-label” as a form of “behavioral control” for children with disruptive behavior disorders, he said, and this is the most common scenario in which medication overuse and misuse can occur.
The lawsuit condemns off-label prescriptions, though the American Medical Association supports The practice of prescribing a drug for a diagnosis that has not been approved by the US Food and Drug Administration for conditions for which it is clinically indicated, that is, supported by research or used successfully in clinical practice.
The tendency toward overuse of antipsychotics in foster children is less indicative of medical incompetence or a lack of care than a profound lack of other treatment options available, Krause said. Although many foster children benefit from medication to help manage their mental health issues, they are also in dire need of other interventions such as psychotherapy and school programs, he said, which are often in short supply.
Psychotropic medications are overprescribed for childcare to compensate for a system that is failing them by failing to provide the comprehensive care and support they need, Krause said.
Judith Chagrin, a social worker who helped run the Baltimore County Welfare System for 35 years before retiring in 2018, also feels that foster children are sometimes given too much, but similarly blames widespread and chronic systemic failures.
“I understand the despair. When a child has behaviors associated with trauma, you will do anything. When a child is in [psychological] Pain for which you want to give them medicines. “This may be the wrong approach,” she said. “But I know it doesn’t come from a place that doesn’t care.”
The lawsuit, filed by the American Civil Liberties Union, Maryland Disability Rights, and Children’s Rights, asserts that 72% of adoptive children prescribed a psychotropic drug lack any psychiatric diagnosis, which “could suggest” that “the drugs are not being given in response to a condition.” Diagnosed mentally healthy. But instead… as a form of chemical restraint.”
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The lawsuit does not explain how children’s medications can be prescribed in the absence of a diagnosis. That practice seems highly unlikely, Krause said, given the professional and procedural standards as well as the operational limitations built into the health care system.
The majority of foster children have Medicaid insurance and their providers cannot bill for services without a diagnostic code. Other forms of insurance likewise require a diagnostic code in order to transfer payments.
“These children are much more commonly given a diagnostic list,” Krause said, since adoptive children are more likely to suffer severe trauma and resulting serious mental and behavioral health and behavioral problems than children in the general population.
Most likely the diagnoses are missing from their file. The lawsuit acknowledges that the lack of a diagnosis could be “at the very least” a record-keeping failure.
Chagrin said that while the problems with the system go beyond poor documentation, much could be solved by better coordinating services and implementing electronic medical records instead of paper, systems commonly used in other health care settings.
Adopted children often have to change providers when they move to a different location, Chagrin says, and their diagnosis and symptoms can evolve over time, necessitating changes in medication. However, the children’s psychiatric records often do not keep track of them, which means that the new provider must start from scratch without any patient history.
The lawsuit recounts an example where a new psychiatrist was forced to piece together a child’s current and previous medication regimens “based on available pill bottles.”
Under the current system, Chagrin said, overburdened workers must sometimes track down uncooperative guardians to obtain permission to obtain and file records. Key information to guide treatment can easily be lost.
Blaming doctors or case workers for missing documents is often unfair. “It’s more complicated than that,” Chagrin said.
Caring for foster children is “complicated at best,” Krause said, given their histories and challenges. He said the “multiple diagnoses” that foster children often face after going through a few different providers — some of which no longer apply as the child gets older — only add to the complexity.
Assigning nurses to manage the medical and behavioral healthcare needs of adoptive children, Shagrin says, can help improve coordination and ensure that diagnoses and medications are tracked and appointments are made and kept. Giving providers access to the relevant record will help them make better decisions about medications and avoid overprescribing.
In addition to inadequate medical records, the suit alleges “failures of oversight” by the state. One of these is informed consent, which means that providers skip the risks and benefits and allow patients to ask questions. The consent is then supposed to be documented.
But children are not able to consent to medication on their own, and caseworkers are usually assigned to consent to them. The lawsuit argues that this makes it unclear whether protocol was followed and more effort should be made to ensure that the adopted children are understood.
According to the lawsuit, the lack of clarity around consent translates to children being adopted in Maryland “routinely” taking medication “against their will.”
Shagreen said she has not seen medicines forced on children.
Krause said it’s “really hard” to get kids, especially teens, to take medication against their will. He said they usually spit them out. Children may also by nature be generally resistant to taking medication, even when needed. Failure to properly exercise and/or document informed consent may not equate to giving medicines to children against their will.
Another oversight failure alleged in the lawsuit is the inadequacy of “secondary review”. This refers to a process in which an external psychiatrist must evaluate and approve the use of certain medications. The suit asks the court to order the state to implement a system for flagging off-base prescribing practices for review.
Krause said this is common in other states. Illinois, for example, requires providers to call a “consent hotline” staffed by psychiatrists when a “significant change” is made to a child’s medication.
The secondary review provides a “check and balance” to the system, which the lawsuit asserts has become a “rubber stamp” operation in Maryland, Krause said.
The secondary review likely identified the medications one of the plaintiffs took from the foster children in the lawsuit, Krause said, referring to a 16-year-old boy identified by his initials, YA, who was taking two antipsychotics, Anticonvulsant, and stimulant. Krause said the approval line “rarely” approves the use of an antipsychotic and a stimulant at the same time because they can have polarizing effects.
YA has been diagnosed with ADHD and dysphoric mood disorder, which is “characterized by intense, recurrent outbursts of anger that are significantly disproportionate to the condition or duration,” and a persistent angry or irritable mood, according to American Psychiatric Association.
Young people used to be located in a hotel, The practice has been heavily criticized for lack of meaningful supervision but is sometimes used as temporary accommodation when other placements cannot be found. YA was left to give his medication, overdosed twice and was hospitalized twice. Returned to hotel between hospitalizations.
Kraus, who was not involved in YA care, said it represented “very bad judgment” on the part of the hospital, and the young man should have been kept there until another place could be found.
“Children staying in hotels makes me crazy. It’s very expensive and shows misplaced priorities,” Chagrin said.
Chagrin said she was told that secondary drug revision was expensive while working in Baltimore County, however, “we bring in the money for the hotel kids.”
‘You get what you pay for’
According to Shannon Hall, executive director of the Maryland Community Behavioral Health Association, the dearth of community services for foster children such as mental health counseling stems from the failed follow-up despite the plan put in place by the Children’s Cabinet in 2008.
The plan aims to prioritize children remaining in home care by closing residential facilities and expanding community behavioral health services. The state reduced the number of home and residential treatment facility beds for foster children a few years ago, but the accompanying expansion of community services never materialized.
“What we have now is a system that just doesn’t have enough capacity,” she said, whether for residential or community care.
Medicaid recipients also routinely face significant barriers to accessing behavioral health services — most providers don’t accept state insurance for low-income individuals or wait months — or even years.
Hall said her group supports a bill slated to be introduced in the current General Assembly session that would propose creating a system of accredited community behavioral health clinics and federally accredited behavioral health providers that provide crisis services, counseling, case management and psychological care 24 hours at a time. regardless of ability to pay.
Hall said the state could take advantage of federal funding at some significant cost.
“You get what you pay for, and the state of Maryland has not invested enough in a strong community behavioral health system,” Hall said. “What happens when we fail to make these investments are the stories that this lawsuit highlights.”
Krause agrees. Foster children’s “enormous need” for comprehensive care means “if you don’t have all those other services, what you’re going to see is the overuse of psychotropic substances,” he said.