Child Welfare and Psychotropic Drug Monitoring: The Role for Social Workers

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Psychotropic treatments for children in foster care can be appropriate, but this form of therapy requires considerable oversight and advocacy from social workers and caregivers. Children do not respond to medications in the same way that an adult may respond because they are constantly growing, their response to medication can be developmentally dependent.

There is a greater risk for a toxic buildup and significant health events can occur without careful monitoring. Social workers should be aware of prescribing guidelines and steps for advocacy and monitoring, but can often feel that becoming involved is beyond their scope or even that medications should be avoided completely in favor of psychosocial care.

Caregivers are often desperate to get psychosocial services, but they may lack accessibility and availability leading to the perception of pharmacotherapy as the only option. Unfortunately, this can also lead to higher rates of prescribing in the effort to help a child.

Although the Trauma-Focused Movement in Child Welfare also seeks a reduction in psychotropic use, it should not be solely aligned with psychosocial services. Children in care are more likely to present with developmental, emotional and behavioral health issues. Responsible and appropriate psychotropic use has a place in caring for them too along with supportive and empathetic caregiving which is always required. Caregivers may need additional training to assist children who have intensive needs.

Psychosocial therapies should be tried first, whenever possible, and then with medication. Social workers can be instrumental in this process. Social Workers can assess the supports and stability in the home, understanding the recommended guidelines for prescribing, providing comprehensive history to prescribing providers and by monitoring so that medication is prescribed and utilized responsibly. Social workers do not need to be doctors in order to participate in decisions for care. Social workers just need the ability to ask good questions, pay attention and advocate effectively – which is basically routine social work practice.

Keep in mind there are always exceptions to the rule, and all assessments should be assessed on a case by case basis. Here are some basic guidelines to begin effective advocacy and monitoring:

1. Provide a comprehensive medical, family and social history, as well as a list of any over the counter or non-psychotropic medications the child may be receiving. Failure to do so could lead to serious adverse effects.
2. Use tools to gather evidence to assess for trauma or current triggers in the home or school and provide this as well. Is a developmental assessment needed?
3. Weigh risk versus benefit to the child. All medications have the potential to help, hurt or do nothing at all. If the benefit does not outweigh the risk, then it should not be tried.
4. Prescribers should also use tools and gather evidence – medical history, academic performance, labs – and make referrals for needed assessments before recommending a treatment path (ex., psychological evaluation, psychosocial therapy is in place) prior to prescribing.
5. Request that only one medication be added or subtracted at a time. By only making one change at a time, the response can be more easily determined.
6. Go low and go slow – start with the lowest dose and move up. FDA approved medications are typically the first line of treatment, but well-evidenced medications may also be used. Ask the physician for evidence and rationale. Seek a second opinion if needed.
7. If it is not working, then it should be discontinued, but never stop a medication without a physician’s direction to do so. Instead return as needed to ensure the physician understands what is happening.
8. Ensure assent and consent from the child as much as possible and be mindful of legal age of consent laws in your state. By involving a child and caregivers in psychoeducation and treatment options, you will strengthen your alliance, empower the child and increase the likelihood that the child will trust and be willing to seek care in the future should it become necessary.
9. A child should typically see the prescriber within 2-4 weeks of a new or discontinued medication and every three months, if things are going well.
10. Every six months to one year, earlier if planned, discuss the reduction and discontinuation of a medication. Every treatment plan designed with a physician should also include a plan to halt a medication in the future and how to do that.

Social Work Advocacy and Psychotropic Drugs in Foster Care

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In 2008, the Fostering Connections to Success and Increasing Adoptions Act required states to begin developing plans to monitor health care for kids in foster care. This was strengthened in 2011 when the Government Accountability Office (GAO) released a study of child Medicaid populations which found that children in foster care with Medicaid received psychotropic medications at a much higher rate than kids with Medicaid who were not in foster care.

Over the last 10-15 years, efforts to legislate, increase awareness about the impact of trauma, engage in advocacy for psychosocial therapies and the need for responsive caregiving have arisen across the country in an attempt to parallel the reduction of unnecessary or inappropriate psychotropic use for foster kids. In spite of those efforts, there is no question that the overprescribing of psychiatric medications for children in foster care has proven a tough practice to change.

The issue of psychotropic use in child welfare populations is clearly one where social workers should be at the forefront, it simply does not gain as much involvement as the psychosocial aspects of practice. Social work practitioners may not see it as being within their scope of practice, but kids in care need social work advocacy in this regard more than ever.

There are a number of reasons why psychotropic monitoring and advocacy has been tough to implement. Too many causes to cover in one article, but one factor may be that all of the efforts to build psychosocial approaches have seemed to exist separately from psychotropic monitoring and reduction plans.

It is unfortunate because better alignment of these initiatives would likely help those living and working with foster care populations to gain a broader perspective and would better illustrate that all therapies, psychosocial or biological, play variable roles. Some states are beginning to implement legislation, but that impact is not yet determined.

Another barrier is that psychosocial treatment modalities are still behind psychiatric medications in terms of research and evidence-based practice. At present, people may simply be conditioned to be more receptive to a medication therapy. Socially accepted norms and the desire for an instant fix can be difficult obstacles to overcome. Effective systems to assist in tracking and authorization of prescriptions for foster kids, as well as hesitant collaborative and information sharing practices between government agencies have proven to be barriers for many states.

Understanding the context of the quick fix

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Governments will wholeheartedly embrace a practice that is thought to offer a quick solution that also suits a budget and it can be several years before any fallout from a poor decision, lack of resources or policy is noted. Twenty years ago the idea of a chemical imbalance really started to become entrenched in American culture. If too much or too few of certain chemicals caused the imbalance, then a psychiatric medication could restore that imbalance. Psychiatric meds were designed to mimic neurotransmitters in the brain – they would “fix” the imbalance in the brain.

It is true that chemicals are important, but more than biology must be considered in developing treatment plans. The idea, intended or not, that mental illness is due to chemical imbalance has largely become accepted, along with a willingness to medicate children as if they will respond exactly as adults. The notion of a ‘chemical imbalance’ is frequently used as the reason for someone’s actions in the everyday vernacular.It’s not his fault, he has a chemical imbalance!” has been further cultivated by pharmaceutical companies and the general misconception of medication as an easy solution.

While none of this was geared directly towards foster children, they are the vulnerable recipients nonetheless. The focus on becoming trauma informed has directly impacted foster care populations and is gaining greater awareness today than ever before. Trauma informed practices can greatly assist in child welfare, but caution should be taken as well. Trauma informed practice does not represent a quick fix either.

Human beings are too complex. A true implementation of biopsychosocial practice which recognizes that age, development, experience, genetics and responsive support each play a role that must be considered in working with kids must be embraced. It is unlikely to be quick or a “fix”, but, in terms of cost it will certainly save in the long run in so many ways.

Polypharmacy and Child Welfare Populations

Kids in care present with a complex variety of behavioral and emotional challenges as a result of chronic poverty, abuse or neglect. They may have unrecognized developmental delays, medical concerns or mental health diagnoses in addition to traumatic experience. In a society where medication has become the accepted first line approach, kids in care are receiving polypharmacy prescribing far more than is appropriate and often without benefit of consistent psychosocial supports. Because foster children can present so intensively, they are susceptible to receipt of psychiatric medication when it may not be warranted.

The effort to medicate behavior, even when no benefit has been realized, makes no sense, but it happens likely increasing the risk of adverse events and placement instability. Caregivers may feel uncomfortable in questioning providers and many do not know what should be monitored and reported. Lack of information and history can be problematic. Providers are often limited in number and in the time they have to give during an office visit. When a foster child refuses a medication, he or she can be accused of noncompliance, but there may be very valid reasons why that child does not wish to comply. Consent is often overlooked or poorly defined.

Side effects associated with some psychotropic medications can outweigh the benefits and clinical trials for children have been in short supply. New science regarding child development suggests that psychiatric medication may have long reaching concerns for children that are not currently understood. In spite of all of the above concerns, efforts to vilify psychotropic use in children should be avoided. Medication can be a helpful therapy, it is simply not the only therapy and it should not be the first type of therapy sought in most cases.

Social Workers need to focus more on psychotropic drug use

Polypharmacy and inappropriate prescribing for foster care populations is more than the latest hot button issue. Efforts have been underway across the nation with varying degrees of limited success for years, often independent of efforts to improve psychosocial supports. There are no easy solutions, a fact that many social workers understand very well. However, social workers can play integral roles in shaping and supporting psychotropic monitoring and oversight at all levels of practice. By improving knowledge, collaboration, highlighting options and advocating for stronger monitoring and consent practices, social workers can make considerable inroads towards positively changing the lives of kids in foster care.

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