Gone are the days of the Clark County child welfare system heavily relying on anecdotes to keep track of foster children and their medications.
Officials with the Department of Family Services want to better monitor the use of psychotropic medications in the system with a new process to review the child’s prescriptions and identify those who need formal psychiatric care outside of drug treatment.
It’s an area in which the county has fallen short. Information is scarce. Some parents have not given consent for their children to take the powerful drugs used to treat psychiatric illnesses such as bipolar disorder, schizophrenia and attention deficit hyperactivity disorder.
On Tuesday, the County Commission approved a partnership among Family Services, the University of Nevada School of Medicine and Mojave Mental Health to screen prescriptions, diagnoses, target symptoms and adverse effects of medication being taken by children. The one-year, $300,455 agreement will go through June 30, 2012, and has an option to renew for three, one-year periods, so officials can examine the data each year.
When a child in the system is prescribed medication or enters care already on psychotropic drugs, the prescription, with the child’s medication log, will be screened by a Family Services nursing team based on legislative criteria.
A child’s case will be red-flagged if the medication is used to treat conditions outside of a manner approved by the federal Food and Drug Administration, if the child is younger than 4 years old and taking a psychotropic medication, if the child is using three or more classes of medication or using two medications in the same class.
If the child’s prescribed medications meet any of these guidelines, that information will be sent to Mojave Mental Health for a second review by an advanced-practice nurse. If that person finds the prescription warrants further review, the case will be passed along to the School of Medicine for a psychiatric review. If the doctor wants additional discussion, a Child Clinical Team review meeting will be held to include a court-appointed consenter, charged with the responsibility of signing off on the child’s psychiatric care, and the prescribing physician to address the next steps.
Commissioner Chris Giunchigliani called for the program to include a strong communication model and a "purple pill du jour" penalty for doctors who overprescribe and to refer such doctors to the state medical board.
Foster parents are heavily relied upon to report medications to the department, but a monthly report developed by Medicaid will serve as a safety net to create a list of children using the medications, which are paid for with taxpayer dollars.
Individual medications can cost taxpayers $600 to $1,000 per month, said Dr. Norton Roitman, a child psychiatrist who has reviewed foster care cases and was involved in crafting state legislation regarding this issue. The distinction between an illness and a feeling can be challenging when a foster child has little or no medical history, he added.
"It’s always been an important value of Department of Family Services to keep a child’s placement," Roitman said. "Everybody from case manager to psychiatrist is very motivated to try to help out. It’s better not to be moving from place to place. I think that’s the motivation behind doctors prescribing to try to settle the child down and keep their placement, but if there’s not a proper diagnosis or history, the doctor has to make an educated guess about what might help."
He said he doesn’t know how many children in the system are prescribed such drugs but that he has "seen it often enough that I’ve become very concerned."
A LACK OF AGENCY DATA
The partnership is a process not seen before by Family Services, which has struggled with budget shortfalls in staffing and technology. Child welfare officials say the lack of data is alarming.
According to national statistics, foster children are medicated with psychotropic drugs three to four times more frequently than children in psychiatric treatment who reside with family.
On any given day, about 3,000 children are in the Clark County system. Of those children, county officials said they have no idea how many are using the medications because of gaps in medical history and changes in foster parents or prescribing doctors. Some children are taking more than one medication at a time — layering drugs prescribed by doctors trying to treat different symptoms without having all of the information available.
Lisa Ruiz-Lee, who has been the department’s interim director since August, said the agency’s data are "fuzzy" and "spotty." The process, she said, will put in place a mechanism to examine the services provided to children in care.
"We don’t want to keep these children on medication if they don’t need to be on medication," Ruiz-Lee said. "Ultimately, what I’m looking for is something not anecdotal. I want something more quantitative with more analysis to figure out the gaps in our system. … We only know what foster parents tell us."
In some instances, medications are prescribed for uses not approved by the Federal Drug Administration but instead are meant to treat certain emotions or behaviors.
"The trauma of abuse and neglect, the grief and the loss of being removed from parents, all of those things create behaviors that could potentially look a lot like something it isn’t," Ruiz-Lee said. "What we have to be careful of is that we don’t attempt to medicate away those behaviors. Ultimately, we need to get to the root cause and treat the trauma."
In such cases, other options, such as therapy, might be more appropriate in dealing with the stress from being separated from family and bounced around unfamiliar foster homes, she added.
Longtime child advocate Donna Coleman said some children are prescribed medications to control their behavior in replacement of therapy, partly because there aren’t enough mental health providers to go around.
"This is something that should have never been," Coleman said. "It’s ridiculous to not know what kids are taking or how many medications they’re on. It’s unconscionable. We’re supposed to be guardians. We’re supposed to be doing a better job. If we’re not doing a better job, we have no business doing it at all."
Contact reporter Kristi Jourdan at firstname.lastname@example.org or 702-455-4519.