In a lawsuit filed this week, two agencies in Maryland run a foster care system that “chemically detains” some children with severe behavioral health problems without providing proper supervision. was accused of overusing psychotropic drugs in the form of “chemical restraint”. It could shed light on a growing dependence on drugs by an overwhelmed system with no other options, experts said.
A federal class action lawsuit filed against the Maryland Department of Social Services and its Bureau of Social Services states that more than one-third of foster children in Maryland are prescribed at least one psychotropic drug. Drugs in this category include antidepressants, neuroleptics, and ADHD stimulants used to treat behavioral health conditions. More than half of these children are taking multiple such drugs, the lawsuit says.
Dr. Louis Krause, professor and chief of the Department of Child and Adolescent Psychiatry at Rush University Medical Center in Chicago, has been accepted into the newest expert on neuroleptics – a class of drugs called antipsychotics in litigation. The term – said should be used with caution.In children, it tends to be overused Among foster children.
The drug is sedating and can cause side effects such as weight gain, diabetes, movement disorders, and cognitive decline.
Foster children are more likely than other children to “behave” and exhibit problematic behaviors due to a variety of factors, including past trauma, environmental instability, and mental health issues such as ADHD, anxiety, and mood disorders. said Klaus. Neuroleptics are prescribed “off label” as a form of “behavior control” in children with disruptive behavioral disorders, he said.
The lawsuit accuses off-label prescribing, but the American Medical Association support The act of prescribing a drug for diagnostic purposes that is not FDA-approved and is clinically indicated, meaning that it is supported by research or has been successfully used in clinical practice.
Kraus said the trend toward overuse of neuroleptics in foster children does not indicate medical incompetence or lack of care, but rather a serious lack of other treatment options available. said. Many adopted children benefit from medications to help manage their mental health problems, but other interventions such as psychotherapy and school programs are also urgently needed and often in short supply, he said. said.
According to Krauss, over-prescription of psychotropic drugs is being used to raise children to compensate for a system that fails to provide the wraparound care and support they need and undermines them.
Judith Shagrin, a social worker who ran Baltimore County’s foster care system for 35 years before retiring in 2018, also feels that foster children sometimes overdo drugs, but likewise, this can be chronic. It is attributed to the serious and large-scale systemic disability.
“I understand the desperation when a child engages in trauma-related behavior. You do anything. When a child enters [psychological] The pain you want to drug them. It might be the wrong approach,” she said. “But I know it’s not out of indifference.”
Monitoring failure
A lawsuit filed by the Civil Liberties Union, Maryland Disability Rights, and Children’s Rights found that 72% of foster children prescribed psychotropic drugs lacked a It may suggest that the drug was not administered accordingly.” But instead… as a form of chemical restraint. ”
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The lawsuit does not detail how medications can be prescribed for children in the absence of a diagnosis. , said this practice was highly unlikely.
Most foster children have Medicaid insurance, and providers cannot claim services without a diagnostic code. Other forms of insurance similarly require a diagnostic code in order to send payment.
Given that foster children are much more likely to suffer severe trauma than the general population and suffer severe mental health and behavior problems as a result, Krause said, “These children are It’s much more common to have a long list of diagnoses.”
Most likely the diagnostics are missing from the file. The lawsuit concedes that the lack of diagnosis may “at least” be a record-keeping failure.
Shagrin says the problems plaguing the system go beyond shoddy documentation, but instead of paper, the system commonly used in other medical settings, there is better coordination between services and electronic medicine. He said many things could be solved by implementing records.
Fosters often need to change providers when moving to another location, and diagnoses and symptoms can change over time, requiring medication changes, Shagrin says. However, children’s psychiatric records often do not follow them. That means new providers have to start from scratch with no patient history.
The lawsuit details an instance in which a new psychiatrist was forced to put together a child’s current and past medication regimen “based on available pill bottles.”
According to Shagrin, the current system requires overburdened caseworkers to seek out and physically file uncooperative parents for permission to retrieve records. Important information to guide treatment is easily lost.
“It’s often unfair to blame doctors and caseworkers for missing documents. It’s more complicated than that,” Shagrin said.
Krause said caring for foster children is “complicated at best” given the history and challenges of foster children. The “multiple diagnoses” (some of which no longer apply as the child ages) only add to the complexity, he said.
By assigning nurses to manage the medical and behavioral health care needs of foster children, Shagrin improves coordination and ensures that diagnoses and medications are tracked, appointments made and maintained. By giving healthcare providers access to relevant histories, they can make better decisions about medications and avoid over-prescribing. .
In addition to inadequate medical records, the lawsuit alleges other “oversight failures” by the state. This means healthcare providers explain the risks and benefits and allow patients to ask questions. Consent is then to be documented.
However, children cannot consent to medication themselves, and caseworkers are usually designated to consent to them. He argues that more effort needs to be made to ensure understanding.
According to the lawsuit, ambiguity about consent leads to the Maryland adoptee taking drugs “regularly” and “against his will.”
Shagrin said he never force-administered drugs on a child.
Krauss said it’s “really difficult” to get children, especially teenagers, to take drugs against their will. Children may be naturally reluctant to take medication, even if it is necessary. Failure to properly exercise and/or document informed consent may not be considered administering medication against the child’s will.
Another failure of oversight alleged in the lawsuit is inadequate “secondary review.” This refers to the process by which an external psychiatrist must evaluate and approve the use of a particular drug. The lawsuit seeks to order the courts to introduce a system in states to flag deviant prescribing practices.
This is common in other states, Krause said. For example, in Illinois, providers must call a “consent hotline” staffed by a psychiatrist when making “substantial changes” to a child’s medication.
Krauss said the secondary review provides “checks and balances” for the system, claiming the lawsuit has become a “rubber stamp” process in Maryland.
Mr. Claus, a 16-year-old boy whose initials are YA, was on two types of neuroleptics, an anticonvulsant, and a stimulant. Krause said that because neuroleptics and stimulants can have polar effects, consent lines “rarely” agree to use neuroleptics and stimulants at the same time.
YA was diagnosed with ADHD and disruptive mood dysregulation. It is “characterized by severe and recurrent outbursts of anger that are significantly disproportionate to the situation in intensity or duration” and is a persistent anger or irritable mood. American Psychiatric Association.
Young people used to housed in a hotel, Widely criticized for its lack of meaningful supervision, it is sometimes used as temporary housing if no other place can be found. He overdosed and was hospitalized twice.
Kraus, who was not involved in YA’s care, said this represented “incredibly bad judgment” on the part of the hospital, which should have kept the young man there until another placement could be found.
“It drives me nuts to have my kids stay in hotels.
While working in Baltimore County, Shagrin was told secondary screening for drugs was too expensive, but said, “I’m paying for kids in hotels.”
“You get what you pay for”
According to Shannon Hall, executive director of the Maryland Community Behavioral Health Association, the lack of community-based services for foster children, such as mental health counseling, is a failure of a plan formulated by the Children’s Cabinet in 2008. It is said that it originated in
The plan was intended to prioritize children remaining in foster care by closing residential facilities and expanding community-based behavioral health services. The state halved the number of beds in group homes and residential care facilities for foster children a few years ago, but the accompanying expansion of community-based services did not materialize.
“What we have now is a system that doesn’t have enough capacity for either residential or community-based care,” she said.
Medicaid recipients also routinely face significant barriers in accessing behavioral health services. Most health care providers either do not accept government insurance for low-income people or have waiting periods of months or years.
Hall said her group will support the bill to be introduced at the current General Assembly session. The measure proposes to establish a system of accredited community behavioral health clinics, which are federally licensed behavioral health service providers that provide crisis services, counseling, case management, and psychiatric care around the clock. increase. Days, regardless of ability to pay.
Hall said states could use federal funding for some of the significant costs.
“You get what you pay for, but Maryland isn’t investing enough in a strong community behavioral health system,” Hall said. “What happens if these investments fail is the story that this lawsuit brings to the fore.”
Klaus agrees. The “great need” for foster children’s wraparound care means that “if they are not receiving all other services, they will see overuse of psychotropic drugs.”
