Child Welfare Ideas from the Experts, #2: Incentivize Psychotropic Accountability

The Chronicle of Social Change is highlighting each of the policy recommendations made this summer by the participants of the Foster Youth Internship Program (FYI), a group of 12 former foster youths who have completed congressional internships.

The program is overseen each summer by the Congressional Coalition on Adoption Institute, with support from the Sara Start Fund.

Each of the FYI participants crafted a policy recommendation during their time in Washington, D.C. Today we highlight the recommendation of Precious Price, 27, a graduate of the University of Connecticut.

The Proposal

Price calls for special federal matching funds for any child welfare agency that employs a child psychiatrist as its mental health director. She also proposes that Congress pilot a local Foster Care Mental Health Center “to better serve the mental health needs of children in foster care.”

The Argument

Foster youth are prescribed psychotropic drugs at a rate that far exceeds that of adolescents in general, and federal research has found that a high percentage of foster youth are prescribed more than one drug at a time. Price cites a 2012 report from the Administration for Children and Families that outlines several reasons for overprescription, including:

• Insufficient oversight and monitoring
• Gaps in coordination between medical, mental health and child welfare agencies
• A lack of access to non-pharmacological treatments

Such misuse of psychotropics would be less likely, Price argues, in a local system where a mental health center was reviewing the medical records of foster youth and a child psychiatrist was in charge of mental health services.

In Her Own Words

“I was diagnosed with a mental illness and placed on two medications that caused severe mood swings and side effects … so severe it has since been recalled for use with children.

I met with my psychiatrist for two years, but my appointments were minimal and short. There was limited time to build trust or a rapport with him, leaving me reluctant to heed any recommendations for prescribed medications.”

The Chronicle‘s Take

The last year of federal policy discussion on child welfare has focused on illicit drug use (particularly opioids) by parents. The Comprehensive Addiction and Recovery Act passed just before Congress adjourned for the summer; the Family First Prevention Services Act remains in play for passage in the fall.

It wasn’t that long ago, though, that lawmakers were focused on the overuse of psychotropics on foster youth. In May of 2014, Sens. Ron Wyden (D-Ore.) and Tom Carper (D-Del.) vowed to “play offense” on reining in psych meds in foster care.

And even before that, President Obama proposed an ambitious $750 million plan to curb psychotropic use in child welfare. Obama’s plan involves two main components: $250 million over five years to “encourage the use of evidence-based screening, assessment and treatment of trauma and mental health disorders,” and $500 million for a Medicaid demonstration project.

Price is proposing the start of something much more modest than all of that. Her gambit is this: If you can make certain that trustworthy professionals are in charge of the mental health treatments for foster youth, you won’t have this problem.

Her first step would be making the person in charge of mental health services in a county or state agency a licensed child psychiatrist. Here, she argues, the federal government can steer systems toward that by agreeing to a special “maintenance matching rate” for agencies that went this route. We’re assuming the matching rate she refers to is for the salary of this mental health director.

Good concept! Hire a child psychiatrist to manage mental health, and get a federal subsidy for doing so. But is that worth the federal investment?

The answers to two questions, in our opinion, would be critical in determining that:

1. What type of people are doing that job now? Are most mental health directors at child welfare agencies people without any specialized training on youth and mental health services? If you’re voting for this in Congress, you’d want to know you were incentivizing a revolution toward this way of thinking, not just subsidizing certain systems to do what most others had already done without free money.
2. Are child psychiatrists in general the right group to incentivize for this job? Because if that’s the only caveat, you have to move forward with the acceptance that a state could hire the worst child psychiatrist there is, and that would be worth incentivizing. Otherwise, this might require more standards on tenure, experience, etc.

Price’s other concept is for Congress to put up the money for one child welfare agency to start a Foster Care Mental Health Center, a team of psychiatrists, therapists, social workers and clinical psychologists that work only with foster youth. The center, she argues would centralize mental health care management for children and likely speed up access to necessary services.

That is a very cool idea. Basically, if we’re reading it right, it would be a tribunal that takes up each child’s mental health plan and is also tasked with review and monitoring. If such a pilot could be shown to drastically and safely reduce the use of psychotropics, you’d have a case for making it a larger program. A large portion of the drugs prescribed to foster youth is paid for with Medicaid dollars, so a federal program that reined in that spending could pay for itself or make the feds money.