Hey, ACS: It’s 10pm. Do you know where your overmedicated foster children are?

More than ten years ago New York State recommended that New York City’s child welfare agency, the Administration for Children’s Services, and its counterparts Upstate, collect data about the use of potent, sometimes dangerous psychiatric medication on foster children.

Last month, ACS admitted it doesn’t do that. 

One of the many reasons foster care is so harmful for so many children is that it dramatically increases the risk that they will be doped up on potent, sometimes dangerous psychiatric medication.  The harm this does to children has been documented over and over, most recently in this outstanding series by investigative reporter Karen de Sa.

The reason it happens is simple: Nobody who loves the child can stop it.

If an agency or a foster parent, or especially a group home or institution, finds that a child is being too difficult, they can just give them pills or shots. It’s often terrible for the children, but it makes the adults’ life a whole lot easier.  Parents can object, but child welfare agencies usually are free to order such medication anyway.  (Sometimes they may need a judge’s approval, but judges don’t love children they don’t know either.)

What’s love got to do with it?

The role of love in the equation can be seen in the comprehensive data that Florida has kept for more than a decade.  When children are placed in foster care with relatives – kinship foster care – they are vastly less likely to be given psychiatric medication.  Why? Because someone who loves a child will put up with more “problem behavior” than someone who doesn’t.

Florida learned this thanks to one of the most visionary leaders in child welfare, the late George Sheldon. When he ran the Florida Department of Children and Families he was appalled by the overuse of such medication. But Sheldon realized that simply getting consent forms rubber-stamped, shoved into individual files and put at the back of a file cabinet wasn’t enough.  He established a comprehensive database to track how every provider in the state was performing (foster care in Florida is overseen by regional private “lead agencies”).  The database tracks use of these meds by age, by gender by race and, as noted above, by placement type.

Even as most of Sheldon’s other reforms were undermined by subsequent administrations and, especially, by the demagoguery of the Miami Herald, the database has remained – and it’s contributed to significant progress: a 30 percent decline in the proportion of foster children who receive these medications since the first report was issued a decade ago.

New York lags behind

In New York State, the City of New York and individual counties run child welfare, with some oversight from the New York State Office of Children and Family Services (OFCS). Even before Sheldon ordered the database in Florida, OFCS was recommending that the City and the counties do something similar.

In a memo dated Feb. 13, 2008, OFCS said:

A quality assurance plan is recommended to monitor the use of psychiatric medications in the out-of-home population. Agencies and districts are encouraged to develop a plan to obtain aggregate data on the use of psychiatric medications for children in their care … and routinely review samplings of individual records. Any concerns should be addressed through a process of continuous quality improvement.

Unfortunately, it was only a recommendation, not a directive.  Local agencies were free to ignore it.  And that appears to be what the New York City Administration for Children’s Services (ACS) has done.

It’s not that they didn’t get the memo.  As recently as last year, a draft document proposing revisions to procedures concerning psychiatric medications makes reference to the existence of the memo – it even includes a link to the memo.

But though the ACS draft talks a lot about private agencies providing data about individual cases, there is no mention of creating a database to aggregate data to detect patterns and trends and see if ACS is making any progress in reducing the overmedication of foster children.

Worse, at a City Council hearing, ACS Commissioner David Hansell acted as though he couldn’t even get the data.  According to the Chronicle of Social Change:

“Currently, ACS does not have access to the data that the council is requesting, but we are advocating for access,” said[ACS Commissioner David] Hansell, who explained that the data is collected by the state’s Medicaid program within the Department of Health. “Once we have access to the information in this system … we believe that we would have much of the information the city council is looking for.”

Is it really that hard?

But OCFS made clear more than a decade ago that agencies like ACS should be aggregating the data themselves.  How hard can it be?  How about just going through the individual files and counting?  As I said in a previous post on this topic, ACS wants to be trusted with a predictive analytics algorithm to target families.  But why should we trust ACS with big data if it can’t even handle the ultimate in small data – simple addition?

In fairness to Hansell, he’s probably not the only ACS commissioner to fail here.  At the time the state memo was written, OCFS was run by Gladys Carrion. She established a strong record as a reformer – so strong that when he first took office in 2014, New York City Mayor Bill de Blasio named her to run ACS, where she did a far better job than Hansell has done.  But de Blasio forced her out because he needed a scapegoat after a high-profile tragedy.  He replaced her with Hansell.

I don’t know what, if anything, Carrion tried to do about this when she was running ACS.  Perhaps she tried and was stymied by the bureaucracy.  Or perhaps she never tried to follow her own advice.

But that’s no excuse for not following it now.

The City Council should pass legislation demanding that ACS compile the database.  And OCFS should turn its recommendation into a directive.

Medicating kids in foster care: Turns out that’s arbitrary, capricious and cruel, too

            What are the odds that a foster child in Kentucky is two-and-a-half times more likely to need to be doped up on potent, sometimes dangerous psychiatric medications, than a foster child in Washington State?

            What are the odds that Kansas foster children really need those drugs nearly three times as often as Pennsylvania foster children?

            How likely is it, really, that a foster child in Texas is more than seven times more likely to need these risky drugs than a foster child in Hawaii?

            Common sense suggests the answer.  Yet these are some of the actual differences in rates at which these drugs are used, according to a recently-released study.

            The study, from PolicyLab at the Children’s Hospital of Philadelphia, compared data on the use of “second generation antipsychotics” on foster children in 47 states and the District of Columbia between 2002 and 2007.  These drugs have become notorious in child welfare circles because, to use the genteel words of the study

these drugs are prescribed to address disruptive behaviors in children despite limited efficacy data and emerging evidence of metabolic side effects that have questioned their use in pediatric populations.

            In other words, their primary purpose often is to keep foster children doped up and docile for overloaded caretakers – notwithstanding the grave risks the drugs may pose to the children.

            The study also looked at the percentage of foster children taking multiple psychotropic medications at the same time.  Here, too, the study found wide variation among the states.

            Both the study and an accompanying press release focus largely on the trends – the extent to which the use of these medications has been increasing or decreasing.

            But at least as significant is the enormous variation among the states. 

We already know that the rate at which children are taken from their parents varies enormously by state.  For example, a child in Iowa is four times more likely to be taken away than a child in Illinois, even when rates of child poverty are factored in.  Yet independent monitors have found that Illinois’ efforts to curb needless foster care have improved child safety.  So either Iowa is a cesspool of depravity with four times the child abuse of its neighbor to the east, or Iowa tears apart far too many children.

The new study suggests that decisions on whether a foster child will be doped up with potentially dangerous psychiatric medication are just as arbitrary, capricious and cruel as decisions about whether to take a child in the first place.  Or as a summary of the study puts it: “…where a child lives seems to influence their chance of being prescribed a psychotropic drug at least as much as the child’s medical needs.”

Texas long as been notorious for the misuse of meds.  Take a look at the “before” and “after” pictures from this story by a Texas television station.  That was just one case.  A segment of the PBS series Need to Know gave an excellent overview of the problem in that state. 

Now, it turns out that the Texas is the doped up foster child capital of America.  More than one in five foster children was on just this one class of medication, second generation antipsychotics, in 2007.  In Hawaii, which uses these medications the least, the figure was 2.8 percent.

GRANDMA VS. THE RX PAD

Unfortunately, the researchers failed to draw one distinction which might explain part of the discrepancy.  The study does not compare the use of meds based on where a child is placed. 

It turns out that once a child is in foster care, the best protection against needless medication is – grandma.

As has been noted previously on this blog, when Florida started looking closely at the problem, the state found that, when foster children are institutionalized, 26 percent of them are medicated. When they're placed with strangers, it's 21 percent. But when foster children are placed in kinship care with extended family, usually a grandparent, only four percent are prescribed psychiatric meds.

It's not hard to figure out why: Grandparents and other relatives are more likely to love these children, and so will tolerate more difficult behavior before demanding a prescription. That's just one indication that the best solution to the misuse and overuse of meds on foster children is not a new law – it's grandma; or, better yet, keeping more children out of the system in the first place.
 

            According to this latest study, Hawaii does best at avoiding doping up foster kids.  Hawaii also is the national leader when it comes to placing those children with relatives.  Florida, which is second best in the nation on kinship care, also did better than all but five other states (of the 47-plus-DC measured) in avoiding using psychiatric meds on foster children – and that was in 2007, before the state began a concerted effort to curb overuse of these medications.  Illinois has the fifth best record on kinship care, and does better than all but nine of the measured jurisdictions when it comes to medication.

            Conversely, Arkansas, Delaware, Virginia and Kentucky all are among the worst both for medicating foster children and for using kinship care. 

            Of course the pattern doesn’t always hold.  Texas actually uses kinship care at a rate above the national average, even as it is worst-in-the-nation for medicating foster children.  But odds are that simply means the proportion of children placed with strangers and institutionalized is so obscenely high in Texas that the use of kinship care doesn’t make up for it.   

            It would have been helpful had the researchers broken down the medication rates  for each state by placement type, if such data were available.

            It also would have been helpful had the researchers thought more about the implications of their own findings.  The only solution they can think of is throwing more therapy and counseling at foster children as an alternative to medicating them.  But the fact that kinship caregivers, who typically get less help than what should properly be called “stranger-care parents,” still resort to drugs so much less often suggests another possibility.  The researchers need to consider whether, for many of these children, it’s foster care itself that’s causing their problems, and return to their own homes or, at least, placement with a relative, might be the best therapy of all.