Author Archives: Children's Monitor

House Hearing On Psychotropic Medication In Foster Care

On Thursday, May 29, the House Subcommittee on Human Resources of the Ways and Means Committee focused additional attention on the issue of the over-use of psychotropic medication for children in foster care. The hearing coincided with the annual “Shadow Day” a House event that arranges to have youth in or formerly in foster care to follow their member of Congress for the day. The issue of over-medication has attracted increasing attention over the past several years with a series of GAO reports, congressional hearings and a new Obama Administration proposal that would target the over medication issue through a coordinated incentive fund with Medicaid and the Children’s Bureau.

Witnesses before the panel included: Joo Yeun Chang, Associate Commissioner of the Children’s Bureau, Dawna Zender Hovenier, The Mockingbird Society, Phil McGraw, Talk Show Host, Dr. Phil, Michael Naylor, Associate Professor of Psychiatry, University of Illinois at Chicago, and Stephen Lord, Director, Forensic Audits and Investigative Services, Government Accountability Office. The star power of Dr Phil helped to draw a big hearing crowd including several of the foster youth as well as several members of the Subcommittee. The consensus was that there is an over-reliance on the use of medication and an agreement that much of it occurs due to a lack of proper health care screening for children and youth in foster care and then a lack of access to proper therapies for patients. As a result, the over-use of medication becomes a fall-back positions in many instances.
Commissioner Chang, highlighted the need for the Administration’s proposal based on current practice which fails to provide the needed therapies and screening for children in foster care. She said, “The existing strong evidence-base in the area of trauma-informed psychosocial interventions warrants a large initial investment to expand access to effective interventions. The ACF proposal for $250 million over five years would fund infrastructure and capacity building, while the CMS investment of $500 million over five years would provide incentive payments to states that demonstrate measured improvement.”

Ms Hovenier discussed her experiences in foster care and what led to her medical treatment and the overuse of psychotropic medications. She testified that she “was ordered into the psychiatric hospital after my social worker told the court I had Borderline Personality Disorder, Major Depressive Disorder and suicidal ideation. I was forced to take strong doses of psychiatric medications and told I could probably never live on my own. Only my CASA and the man who became my father agreed with me that I didn’t need the drugs. The seven months I was locked up and forced to take drugs against my will felt like being in jail.” Ms Hovenier also suggested that youth in care have a right to request a second medical opinion regarding their care.

Dr Phil repeated some of his remarks delivered earlier that afternoon before a luncheon of foster youth and members of Congress when he said, “Prescription psychotropic drugs can change and even save lives, but when it comes to these vulnerable children, these drugs are too often misused as ‘chemical straight jackets.’ This is a haphazard attempt to simply control and suppress undesirable behavior, rather than treat, nurture and develop these treasured young people.” He said it would be wrong to pour more money into the same system but that investment into a system that would provide better health care would be worthwhile and that we had to make a greater effort at supporting these children including making a better effort at reunification.

Michael Naylor, discussed some of the recent efforts and successes of the state of Illinois to monitor and reduce the overuse of medication for the foster care population in the state. Dr Naylor said, “The Illinois model of providing consent for psychotropic medications for foster children and monitoring the use of these medications is widely regarded as a pioneer and leader in this arena and has received considerable attention…a well-designed and implemented medication consent and oversight program that provides effective longitudinal oversight of a youth’s care and monitoring of prescribing patterns can improve the continuity and quality and increase the cost-effectiveness of care provided to foster children.” The GAO witness reiterated some of the findings of last week’s GAO report.

Dr Phil also indicated that he had signed onto a letter signed by more than 100 organizations in support of the Administration’s budget request for the joint ACF-Medicaid proposal.

Health Policy Opportunities to Prevent Violence Against Women, Children & Families

On Wednesday, April 30, Futures Without Violence and the National Health Collaborative on Violence and Abuse (NHCVA) conducted a Capitol Hill briefing to address strategies to utilize the health care system in a way that can prevent family violence. Speakers included Richard Krugman, MD, the Office of Health Affairs, University of Colorado Denver; Deb Levine, MA, Executive Director, Youth + Tech + Health; Diana Cheng, MD, Project Connect Maryland; Howard Koh, MD, MPH, Assistant Secretary for Health, Department of Health and Mental Hygiene; and Brigid McCaw, MD, MPH, Chair, National Health Collaborative on Violence and Abuse.

Dr Krugman, discussed his work on child abuse and neglect issues. He was a member of the U.S. Advisory Board on Child Abuse and Neglect when they issued their findings in 1990. He summarized what was concluded then, and continues even today, that we have hundreds of thousands of children being abused and neglected each year. Further, that the system we have designed to address these families is dysfunctional and that we end up spending billions of dollars a year to address the failure to respond. He concluded that the Commission he was on had too many recommendations (31), and because they did not offer Congress a “silver bullet” to fix the situation, the recommendations were ignored. He also noted a lack of commitment to the issue by all administrations, noting the Clinton Administration’s lack of interest in the topic at the time he was on the Commission.

Dr Krugman also talked about the need for much more research, pointing out that children respond differently to being victims of abuse but we have a limited ability to understand this result. He suggested that the March of Dimes model might be the best model for advocacy, noting their history of forming in response to the past polio epidemics of the forties and fifties that took a little over 1,000 lives per year. They mobilized around a single cause and grew from there.

Dr.Cheng focused her discussion on recent research and on-going work in Maryland. Starting in Baltimore, research determined that the number one killer of women who are pregnant or within a year of their pregnancy was homicide. Further work and research determined that in two-thirds of these homicides the perpetrator was the partner or former partner. In some instances these homicides also include the infant. They also determined through surveys of pregnant women that 7 percent were experiencing physical abuse during their pregnancies. Building on these finding Maryland is working on addressing intimate partner violence (IPV), training providers including Obstetricians and Gynecologists, and integrating IPV assessment into Title X Family Planning Programs and other health provider contacts.

Additionally, the briefing highlighted further opportunities in health care to reduce domestic and dating violence and adverse childhood experiences (ACE), and new technology (apps) that promote safe and healthy relationships. 

More Details on Changes to CFSR Data Elements

The Children’s Bureau (CB) continues to provide details and solicit comments on the third round of the Child and Family Services Reviews (CFSRs). On Monday, April 28th CB sponsored a conference call to describe some of the changes that will be implemented as states embark on this review. The following highlights were discussed on the call and can be found in the CFSR guidance and proposed rule.

  • State success will be judged against a national standard instead of previous reviews that made assessments based on a state reaching the 75th percentile of states. The national standard will also be an attempt to build in factors unique to states.
  • In terms of child maltreatment the review will assess all children that are screened in for a report of child abuse and neglect instead of just children who are substantiated as victims. The review will then look at the instances when children were reported again within a 12 month period. States have an initial screen of child abuse reports and then determine whether a child is substantiated as abused or neglected. Some states use of differential response means a child is either determined as a “victim” or “non-victim.” This new standard would consider all children screened in to better assess reoccurring maltreatment.
  • Another data change for the CFSR is the use of entry cohorts, or looking at those children that enter care rather than assessing children who leave or children at a point in time. (The Adoption and Foster Care Analysis and Reporting System (AFCARS) determines the annual foster care statistic with a point in time count at the end of the federal fiscal year.)
  • The CFSRs will also assess permanency in a different way by examining data not just on children leaving foster care for reunification but also leaving foster care for adoption and subsidized guardianships.
  • The CB will also start to examine children who have been in foster care for two years in an effort to have a better assessment of some long term foster care placements.

Offset Issue Holds Up More Child Welfare Legislation

Legislation that would renew the Adoption Incentives Fund and the Family Connections Grants, programs that officially expired in October of last year, is also in limbo due to the cost-offsetting issue reported on last week.

In October the House of Representatives approved the Promoting Adoption and Legal Guardianship for Children in Foster Care Act (H.R. 3205) that would extend both the Adoption Fund and Connection Grants. The bipartisan bill was introduced in late September by Committee on Ways and Means Chairman Dave Camp (R-MI), Ranking Member Sandy Levin (D-MI), Human Resources Subcommittee Chairman Dave Reichert (R-WA), and Ranking Member Lloyd Doggett (D-TX).

The Senate responded with their version of the legislation in December when the Senate Finance Committee reported out two bills: one that extended the adoption program and one that did that and also included provisions that related to youth and victims of sexual exploitation (S. 1870 and S. 1876).  With the Senate unable to act, the negotiations over a budget deal that was taking place at the same time ended up taking all available “offsets.” When Congress returned in January of this year, the funding to pay for the extension of the $15 million for the Family Connections Grants was gone.

If the Family Connections Grants are not extended there are several programs across the country that will lose the third year of their three year grants—and of course there will be no more future grantees. The Family Connections Grants fund four different programs:

  • “kinship navigator” programs that provide resource and referral services to any kinship families,
  • “family finding” programs that use various strategies and technologies to help children in foster care find their families,
  • “Family Group Decision Making” programs which attempt to bring together families and friends to potentially strengthen families and prevent placements in some cases, and
  • “Residential Drug Treatment” programs that target the substance abuse problems of parents involved in child welfare and foster care.

Under the Adoption Incentive Fund, states are currently rewarded for an increase in their overall adoptions ($4000 per child), special needs adoptions ($4000) and older child adoptions—considered a child age 9 or older ($8000). In the last reauthorization a $1000 incentive was included for states that experienced an increase in their adoption rate. This part of the award was only provided to states if the funding did not run out after the other categories were provided. The House and Senate bills would take slightly different approaches in how this formula would be re-vamped and how much support a new incentive would reward kinship placements.

Call your Senator and Representatives: Congress should finish their work to extend the bipartisan Adoption Incentives Fund and Family Connection Grants.