Often psychotropic medications are used to provide sedating effects to manage aggression or undesirable behavior rather than to address an underlying mental health issue. Psychotropic medications can be beneficial for the treatment of mental health disorders such as depression and anxiety, but are not effective for treating the effects of trauma, neglect, or abuse (Brenner, Southerland, Burns, Wagner, & Farmer, 2014). Foster youth and parents report concerns about and feeling uncomfortable with the number and type of medications prescribed to the children in their care (Barnett, Boucher, Neubacher, & Carpenter-Song, 2016).
State Plans for Child Welfare Services, 42 USC § 622 requires a “plan for the ongoing oversight and coordination of health care services for any child in foster care placement” and “the oversight of prescription medicines, including protocols for the appropriate use and monitoring of psychotropic medications”(2017).Oversight for the prescribing and use of psychotropic medications in foster care varies significantly across the Unites States (Mackie et al., 2011; Mackie, Hyde, Palinkas, Niemi, & Leslie, 2017). Best evidence supports the use of medication consultation to decrease the overuse of medications in this population (Barclay, et al., 2014) This project, now in the third year of funding, is comprised of an interprofessional team as a joint venture between the state Department of Human Resources, Family Services Division and a local academic institution to reduce psychotropic medication use in the foster care population across a 10-county catchment area. Services were funded through the state department.
The team was directed by a doctoral-level Board Certified Behavior Analyst (BCBA-D) who is a professor in the Psychology Department and director of the Applied Behavior Analysis (ABA) graduate program. Other team members included a behavioral pharmacologist who is a professor in Psychology Department and affiliated with the Cognitive and Behavioral Sciences graduate program, a child and adolescent psychiatrist who is affiliated with local hospital, psychiatric mental health nurse practitioner, four BCBAs who are affiliated with the Psychology Department, and numerous graduate students in the ABA program. Planning included leadership and case workers from the state department of health and human services.
The team initially developed methods for reviewing medication profiles for youth in foster care to identify high risk clients. Referral were provided to the team from case workers, foster parents, and data from the medication profiles. The behavioral analysts contacted foster families and caseworkers to offer services at no cost to the patient or family. Clients who consented to services received individualized care in both the home and school setting. The medical staff provided medication consultation and recommendations for deprescribing psychotropic medications.
Barriers to providing behavioral services included: lack of follow up from case workers often related to high turnover, resistance from foster families or teachers to interventions, commute time to rural locations, and lack of consistency with parent training and implementation.
Barriers to providing medication consultation included: outdated data from medication database, resistance from providers to adjust prescribing practices, limited understanding of indications and dose ranges, provider schedules, access to mental health providers.
In an attempt to engage and inform foster parents regarding psychotropic medications, a video series was developed. Video topics covered preparation for medication appointments, medication indications, risks and benefits, and basic behavior management tools.
Future goals for the team will focus on developing a standardized tool for deprescribing psychotropic medications and increasing access and awareness of nonpharmacological interventions to provide best practice care for children in foster care.
Overprescribing of psychotropic medication in foster care youth is a critical health disparity and significant contributing factor to increased healthcare expenditures and adverse outcomes. This project implemented an interprofessional team approach to reduce psychotropic medication use with medication consultations, and behavioral and educational interventions aimed at foster youth and parents, case workers, and mental health providers.