Foster children and psychiatric drugs

Documenting trends and problems in one state’s child-welfare system

Michelle Cole and Brent Walth, The Oregonian

Children in foster care are being placed on psychiatric drugs (or psychotropic drugs, as they’re often called) far more often than other kids. Many children in protective custody do face more serious mental health problems – they’ve either witnessed abuse and neglect, or have been victims themselves. But when the state plays the role of guardian, who makes the decision to put a child on a powerful psychiatric drug, and why?

What we found

Our story found that nearly 30 percent of Oregon foster children are on psychiatric drugs – a rate more than four times higher than children not in protective custody. We found that the state wasn’t keeping track of the children on these drugs and had ceded control of medication decisions to foster parents, who have (thanks to Oregon’s reimbursement plan) a financial incentive to identify problems with kids in their care. We also found state law governing the use of psychiatric drugs and foster children wasn’t being followed, that medical reviews for children on these drugs were inadequate, and that state officials ignored the warnings of experts that foster parents should not have the final say about when children are put on these medications. The story has prompted efforts at reform with the state’s child-welfare agency.

How we got the story

Our story started with basic, solid reporting by Michelle, a veteran journalist who has covered child-welfare issues. The more she spoke to foster parents, the more she noticed how many spoke of foster children placed on psychiatric meds. She learned it wasn’t just Ritalin and other attention-deficit disorder drugs, but also antidepressants and antipsychotics. She wanted to write about it – but the challenge seemed daunting. Medical records and child protection files are confidential. How could someone measure the extent of psychiatric drug use?

Michelle suggested the story to Brent, a member of the newspaper’s investigative team. Together we tried to understand how a child in foster care might get psychiatric drugs, who makes the decision and – most importantly for our early reporting – who pays for the drugs. We soon learned that all kids in foster care are automatically covered by the state’s Medicaid program.

This discovery led us to the following steps:

We turned to Medicaid records to find out who is getting what drugs.

By “who,” we don’t mean individual children; those records remain confidential. But your Medicaid office should be keeping highly detailed records about what medical services taxpayers are paying for. The Oregon Medicaid office keeps track of which children were in foster care during the year, and as a result, analysts could create a subset of those children to look at medication patterns, diagnoses and medical care. These records are coded, so it’s possible to know, for example, how much Prozac is dispensed to children. These data should be public records (as long as the detail does not violate an individual patient’s identity or medical privacy) because it is recording how public money is spent.

We looked for allies inside the system.

Child welfare officials did not want to talk about this topic, told us it was really complicated, and resisted our requests for help. But as it turns out, they didn’t control the crucial data. Those folks worked in the Medicaid office, which in Oregon has a superb research staff. Folks there not only understood that this was an important issue, but believed it was their responsibility to help the public understand what is happening within a taxpayer-funded health care system. We asked a ton of questions about how the data were kept and what they might tell us.

We looked for research that others had already done.

We wondered if anyone had already looked at this question. The answer was yes. Using our state’s public records law, we asked for any and all reports and analyses performed by state child welfare officials on the issue of psychiatric meds and children in foster care. We got about a half dozen memos, written by one of the agency’s analysts, describing the medication rates and trends that they had already discovered in Medicaid data. While the Medicaid office did several analyses for us, these memos offered the clearest explanation of what was going on and what state officials already knew.

Outside researchers were also very important. Using Pubmed, we searched on line for published research on the issue of psychiatric drugs in foster care. We found it was very difficult to compare medication rates across states. But we did find experts who could talk about what they found and give us advice on what questions we should be asking. (One discovery: Researchers use the same Medicaid data that we were turning to – confirmation we were on the right track.)

We looked for what other people were saying about this issue.

We spoke to a wide range of people involved, in child welfare, including, foster parents, caseworkers, legal advocates and judges. We filed public records requests for any and all communications (letters, memos, e-mails, reports, etc.) in which state officials discussed this topic. We soon discovered the state had organized a task force three years earlier in which about a dozen people involved in child welfare looked into the use of psychiatric drugs and issued a series of recommendations. We asked for the panel’s report under the state’s public records law; state officials first disavowed knowing about the report, and then declined to give it to us. We got copies anyway from people who were frustrated that years and gone by and the panel’s recommendations had not been made public or fully followed.

We looked at the rules here and elsewhere.

We found the state’s child-welfare agency had just crafted a new set of rules regarding psychiatric drug use and foster children that included some of the task force’s recommendations. But we also found some recommendations had been ignored or changed, and we sought to demonstrate what those omissions and changes meant. We also looked at the rule-making process, in which the public is asked to comment. These comments and critiques of the rules led us to more sources and new areas of reporting.

We also looked to other states to see what kind of oversight they had on psychiatric drug use among foster children. We discovered several states had introduced aggressive programs to monitor the use of these meds, which provided an important contrast to Oregon’s system.

We learned all we could about the drugs in question.

These drugs include stimulants (such as Ritalin, for attention-deficit disorder), anti-depressants, anti-psychotics, mood stabilizers and sedatives. Even within those classes we found a wide range of drug types. Our research requests to the Medicaid office produced a list of psychiatric drugs dispensed to foster children, and a count of which ones were dispensed most often. We then turned to a lot of experts, including physicians and nurses, as well as Web sites of the drug companies and the U.S. Food and Drug Administration. Most helpful was the PDR, short for the Physician’s Desk Reference, considered to be the standard guide on drugs. It’s available at most research libraries and on Nexis.

We looked for stories of foster children on psychiatric drugs.

While all the other steps made the story possible, this step made it meaningful. We didn’t want to write a dry story that was filled with only numbers. We wanted real-life tales. But we found this is a step fraught with problems: We wanted specific cases but without identifying individual children. We spoke to caseworkers, foster parents and legal advocates, who related anecdotes and stories. In each case we did what we could to verify details, but always with an eye to keeping identifying information out of the newspaper.