Less reliance on powerful drugs for Arizona foster kids, report shows

The Arizona Health Care Cost Containment System — known as AHCCCS — posted the long-awaited report on its website May 27, days before a deadline Gov. Doug Ducey’s office gave the agency in April.

The update comes four years after an AHCCCS report, based on 2008 prescription data, found disparities in how often foster children were given the drugs, compared with children not in foster care who were enrolled in AHCCCS.

“Caring for Arizona’s most vulnerable children is a top priority for the governor, and we will review the report closely as we seek ways to continuously improve our efforts,” Ducey spokesman Daniel Ruiz said in an email.

Psychotropic drugs — including antidepressants, antipsychotics and drugs for attention-deficit disorder — can have serious and lifelong side effects, including weight gain, neurological complications and for antidepressants, increased risk of suicide.

The report found the percentage of foster children receiving psychotropic medications decreased from 20.3 percent in 2008 to 14.9 percent in 2014.

Compared with children not in the foster care system, in 2013, foster children were 4.1 times more likely to get prescribed the drugs, compared with 4.4 times more likely in 2008.

But the disparity between foster and nonfoster children on five or more drugs has worsened.

In 2013, the percentage of foster children on five or more psychotropic drugs in 2013 was 9.5 times that of nonfoster children, compared to 9 times in 2008.

POLYPHARMACY

Polypharmacy — the use of multiple drugs at one time — is a troublesome aspect of modern medicine, rooted in the belief that drugs can fix any problem, said Dr. Gary Hellmann, child and adolescent psychiatrist at Banner-University Medical Center Tucson.

“Polypharmacy is this grand experiment in modern psychiatry,” he said. “I think in 50 years, psychiatrists will look back and say, ‘What were they thinking?’ This is going to be the thalidomide scandal from the 1950s — 50 years from now.”

Until it was banned in 1962, thalidomide was commonly prescribed for morning sickness, and caused severe disabilities in thousands of babies.

Among foster children, polypharmacy can be driven by demands of caregivers or providers, who can pressure doctors to “fix” a child’s behavior, Hellmann said.

“That has to do with getting these ultimatums from foster families, group homes, CPS workers sometimes, who say, ‘You know, we’re going to lose this placement,’” if a child’s behavior doesn’t improve, he said. “And that gets our attention. We don’t want another disruption.”

It takes time to address behavioral problems, especially those rooted in trauma, using psychosocial, nonmedical interventions, and the overwhelmed system is short on time, he said.

Hellmann said he actually expected the number of foster children on multiple drugs would be higher, but that doesn’t mean the results are good, he said.

“These kids have the greatest number of risk factors, and we are using medicines to help them solve their problems, when we should be making greater efforts at social interventions,” he said.

The state’s best practice guidelines say psychotherapeutic interventions should be the first step before prescribing medication to children under 5.

LIMITS OF STUDY

The report notes that its comparison of foster children and nonfoster children covered by AHCCCS is “somewhat misleading.” Foster children are much more likely to have heightened behavioral health needs due to higher rates of trauma and other mental health conditions.

“It is not surprising that children in foster care have higher penetration rates for behavioral health services than the general Medicaid population and correspondingly, higher rates of psychotropic medication prescriptions,” the report said.

Overall, the report had some encouraging statistics, but shows continued oversight is necessary, not only to prevent overmedication, but to ensure children have access to behavioral health care — with or without drugs — when it’s truly needed, said Beth Rosenberg, director of child welfare at the Phoenix advocacy group Children’s Action Alliance.

The U.S. faces a shortage of child psychiatrists, which can lead to over-reliance on medication as a quick fix or lead to access problems, when children can’t see a doctor in a timely manner, she said.

“What we hear from the behavioral health community is that there are not enough providers out there to serve all the kids and adults that need it,” she said.

Newly signed state legislation aims to address this by allowing foster children to seek treatment from providers outside their state insurance’s network, if they aren’t able to get an appointment within 21 days, she said.

DEMANDS FOR STUDY

Sen. Debbie Lesko, R-Peoria, was frustrated in 2013 by AHCCCS’ lack of response to requests for an update to its 2012 report on psychotropic drugs and foster kids, which used 2008 data.

An April 10 Star article about the delayed report prompted Lesko to ask the governor’s office to give AHCCCS a deadline of the end of May.

The prescription data used to compare and foster and nonfoster children is now 2½ years old.

When AHCCCS began the study two years ago, 2013 was the most recent year for which there was complete data on prescription utilization for those populations, the report said.

But in that time, the state’s foster care population has continued to swell: Since 2008, the state’s foster care population has exploded by 92 percent.

As of September 2015, more than 18,600 children were in out-of-home care in Arizona, compared with about 15,000 in 2013.

The report says AHCCCS will reproduce the study on an ongoing basis with more recent data, but spokeswoman Monica Coury said the agency hasn’t specified when that will happen.

“Due to the resource-intensive nature of these reviews, we have not established set time frames,” she said in an email.

Sen. David Bradley, D-Tucson, who has worked in child welfare for three decades, emphasized the need for continued oversight of foster children’s health-care quality.

“There has to be a perpetual vigilance here,” he said. “It’s never going to be adequate enough to take a snapshot. The oversight has to be perpetual.”

Bradley wants to empower — and fund — the hundreds of foster care review boards across Arizona to collect data on the children whose cases they review anyway.

“That’s a great opportunity to collect data,” he said. The civilian-run, independent boards are “an obvious place for that oversight.”