Chapter 1
THE COUNTIES HAVE NOT ALWAYS PROVIDED ADEQUATE OVERSIGHT TO ENSURE THE APPROPRIATENESS OF THE PSYCHOTROPIC MEDICATIONS THAT CHILDREN IN FOSTER CARE RECEIVE
Chapter Summary
In 2015, the California Department of Social Services (Social Services) and the Department of Health Care Services (Health Care Services) adopted guidelines (state guidelines) for the safe administration of psychotropic medications to children in foster care (foster children). Although the state guidelines are a valuable tool that counties should use to ensure that foster children do not receive inappropriate or unnecessary psychotropic medications, some counties have yet to adopt them. Consequently, when we reviewed the case files for 80 foster children at the four counties we visited—Los Angeles, Madera, Riverside, and Sonoma—we found that many foster children had been authorized to receive psychotropic medications in quantities and dosages that exceeded the state guidelines. Although exceeding the state guidelines may be medically appropriate in some circumstances, we found no evidence that the counties had followed up with the health care providers in these cases. When counties do not follow up regarding prescriptions that exceed state guidelines, they cannot ensure that they are reducing foster children’s exposure to potentially inappropriate medication interventions.
Further, the counties have not always ensured that they followed best practices relating to the health services that foster children should receive in addition to their psychotropic medications. Guidelines from the American Academy of Child and Adolescent Psychiatry (academy guidelines) state that follow‑up visits and corresponding psychosocial services are important aspects of mental health treatment. However, the State’s data show that in fiscal year 2013–14, more than 29 percent of the State’s foster children who had a filled prescription for a new psychotropic medication did not have a corresponding Medi‑Cal claim for a follow‑up medication service within 30 days after the prescription was filled, thus increasing the risk that any harmful side effects would go unaddressed. In addition, a significant number of foster children do not appear to have received psychosocial services around the time of their prescriptions for new psychotropic medications; therefore, the children may not have received the services needed to treat their conditions.
Finally, we found that a significant number of foster children had at least one paid prescription for psychotropic medications without required court approval or parental consent, which is a violation of state law. Specifically, 28 of the 80 foster children in our case file review had at least one prescription for psychotropic medications without court or parental authorization. Further, when we looked at the state data, we found 65 percent of the foster children statewide with paid prescriptions for psychotropic medications were prescribed at least one psychotropic medication without the appropriate authorization recorded.
By Failing to Adopt the State Guidelines, Some Counties May Be Missing an Opportunity to Better Protect Foster Children From the Risks of Inappropriate or Unnecessary Psychotropic Medications
As we discuss in the Introduction, Social Services and Health Care Services developed recommended state guidelines in 2015 for the safe administration of psychotropic medications to foster children. By following these guidelines when reviewing health care providers’ requests to prescribe psychotropic medications, counties can better ensure the appropriateness and necessity of the psychotropic medications foster children receive. However, we found that some counties have yet to adopt the state guidelines and thus may be missing an opportunity to better protect the foster children under their care.
In developing the state guidelines, Social Services and Health Care Services intended to create a tool that prescribers, pharmacists, and courts could use when reviewing foster children’s prescriptions for psychotropic medications. According to state law, a foster child cannot receive psychotropic medications without the authorization of either a juvenile court or the child's parents, depending upon whether the court has delegated the ability to make such decisions to the child’s parents. To receive court authorization, a health care provider must fill out an application requesting approval to prescribe the medication. The county then reviews these applications and should determine whether the prescription complies with the state guidelines. To the extent that a prescription exceeds the guidelines, the county should follow up with the provider to inquire about the prescription’s medical necessity, if the prescriber did not thoroughly explain this in the application. If the county does not believe a provider has adequate justification for exceeding the state guidelines, the county should recommend to the court that it not authorize the prescription.
However, only two of the four counties that we reviewed have adopted either the 2015 state guidelines or very similar guidelines. For example, Los Angeles County adopted guidelines that are very similar to the state guidelines. Like the state guidelines, Los Angeles County’s guidelines generally only allow foster children to be concurrently prescribed one psychotropic medication per class.6 Furthermore, the State adopted Los Angeles County’s dosage parameters as part of its guidelines. The only significant difference between the two sets of guidelines is that Los Angeles’ guidelines allow three psychotropic medications for children nine years and older rather than for children who are 12 and older, as the state guidelines recommend. According to the medical director of Los Angeles County’s Juvenile Court Mental Health Services (LA Juvenile Court Services), Los Angeles’ guidelines for children aged 9 to 11 differ from the state guidelines because anxiety disorders often manifest in children around the age of nine.
In part to ensure that health care providers comply with its guidelines, Los Angeles County established the LA Juvenile Court Services, a unit within its Department of Mental Health. LA Juvenile Court Services assists the juvenile court in making decisions to approve or deny prescribers’ requests to initiate or continue psychotropic medications for foster children. LA Juvenile Court Services’ staff includes a child psychiatrist and a pharmacist, both of whom review each request to ensure its adherence to the county’s guidelines. If a request for medication is outside these parameters, the LA Juvenile Court Services reviewers will generally follow up with the prescriber to determine if the prescription in question is medically necessary. If the reviewers determine that the request is not safe and appropriate, they will recommend that the court either deny the request or approve it for only 45 days, with the expectation that the child’s medication regimen will be changed after that time.
Similarly, Madera County relies upon the state guidelines when reviewing prescriptions for psychotropic medications for foster children. For example, the policies of Madera County’s Child Welfare Services Division (Madera Child Services) require the county’s public health nurse to review all requests for court authorizations to identify proposed psychotropic medications that are outside Los Angeles County’s dosage parameters (which are also the parameters the State adopted). In addition, the public health nurse also determines whether prescribers are seeking court approval to prescribe multiple psychotropic medications within the same class or more psychotropic medications than foster children should take based on their age according to the state guidelines. The public health nurse documents her review of these and other risk factors on a psychotropic medication monitoring review form. If the public health nurse has concerns about the proposed medications based on the risk factors she has identified, the nurse and the child’s assigned social worker will contact the health care provider. If county staff are unable to resolve their concerns with the provider, they will document their opposition to the prescription authorization request with the court.
In contrast, Sonoma County uses its own standards, which are less specific than the state guidelines, when reviewing requests for psychotropic medications. Specifically, in May 2015 the Sonoma County Department of Health Services, Behavioral Health Division (Behavioral Health Division) entered into an intracounty memorandum of understanding with the Sonoma County Department of Human Services, Family, Youth and Children’s Division (Children’s Division) to provide pediatric psychiatrists to review requests for court authorization for prescriptions for psychotropic medications for foster children. However, according to the Behavioral Health Division’s Medical Director, the reviewing psychiatrists are expected to ensure that proposed prescriptions adhere to a 1999 county policy rather than to the state guidelines. Although this county policy is consistent with the state guidelines in certain areas, it references another document that contains dosage restrictions based on Los Angeles County’s 1997 dosage parameters rather than the State’s current dosage standards. In addition, the policy does not contain any specific age‑related restrictions on psychotropic medications. Behavioral Health Divisions’ medical director acknowledged that Sonoma County’s internal policies are outdated, and he stated that the county is in the process of updating its policies to reflect the guidelines that Social Services and Health Care Services released in 2015.
Riverside County also uses its own, less specific guidelines when reviewing foster children’s psychotropic medication prescriptions. According to Riverside County’s policies, a Riverside University Health System—Behavioral Health (Riverside Behavioral Health) child and adolescent psychiatrist reviews all requests for court authorization for foster children’s psychotropic medications. However, according to Riverside Behavioral Health’s medical director, the psychiatrist ensures that the prescriptions adhere to a 2011 county policy that differs significantly from the state guidelines. For example, Riverside’s policy allows the concurrent prescriptions of two medications within the same class without requiring documentation; however, the state guidelines recommend that children receive no more than one medication within the same class without justification. Further, unlike the state guidelines, Riverside County’s policy does not contain any specific age‑related restrictions on psychotropic medications. Finally, Riverside County’s policy contains specific maximum dosage limitations for antipsychotic medications only; it requires all other prescriptions for psychotropic medications to comply with the U.S. Food and Drug Administration’s recommended maximum dosages unless the providers document their reasons for exceeding these limits.
According to Riverside Behavioral Health’s mental health services administrator, Riverside County has been working to implement the state guidelines. Riverside County’s Public Health, Behavioral Health, and Public Social Services departments have met and agreed to develop a memorandum of understanding that will adhere to the state guidelines. Riverside County’s Public Social Services department has developed a draft of this memorandum, and Riverside Behavioral Health will offer an amended draft for all three county departments’ consideration after our audit report is released.
When counties such as Sonoma and Riverside do not use state guidelines, they miss a valuable opportunity to improve their oversight practices. Not surprisingly, we generally found more instances in Sonoma and Riverside County of authorizations of prescriptions for foster children that exceeded the state guidelines than we did for Los Angeles and Madera counties. We believe that the state guidelines are a valuable tool that counties should leverage to improve their oversight of foster children who are prescribed psychotropic medications.
Foster Children Throughout the State Have Been Authorized to Receive Amounts of Psychotropic Medications That Exceed the State Guidelines
As previously discussed, the state guidelines include maximum amounts and dosages of psychotropic medications that foster children should receive. Nonetheless, when we reviewed the case files for 80 foster children at the counties we visited, we found that many had been prescribed psychotropic medications in amounts and dosages that exceeded the state guidelines. Although prescriptions that exceed the state guidelines may be appropriate under some circumstances, we often found little indication that the counties had followed up with the providers in question to ensure the appropriateness of the medications. Further, our review of statewide data (state data) from Social Services and Health Care Services indicates that many foster children prescribed psychotropic medications statewide may have received these medications in excess of the state guidelines. As discussed in the Introduction as well as in Chapter 2, we have concerns about the accuracy and comprehensiveness of the state data. Nevertheless, we used them in our analysis because they are currently the best data available that speak to the number of foster children prescribed psychotropic medications statewide.
In response to a recent state law, the Judicial Council of California (Judicial Council) adopted new and revised forms—which became effective in July 2016—to be used in the court authorization process for foster children’s psychotropic medications. The proper completion of these newly revised forms should provide county staff with additional information necessary to identify instances when foster children are prescribed psychotropic medications in amounts or dosages that exceed the state guidelines. Among other things, these revised forms require prescribers to explain for each foster child why they prescribed more than one psychotropic medication in a class and dosages that are outside the state guidelines. If these forms are not properly completed, county staff will need to follow up with prescribers to obtain information necessary to ensure that the prescriptions beyond the state guidelines are appropriate.
Fourteen Percent of the Foster Children We Reviewed Were Authorized to Receive Multiple Psychotropic Medications From the Same Drug Class
The state guidelines recommend that a foster child should take no more than one psychotropic medication at a time from each medication class. Common classes of psychotropic medications include antipsychotics, antidepressants, mood stabilizers, stimulants, and antianxiety medications. The concurrent use of multiple psychotropic medications from the same class can lead to extremely harmful side effects. For example, a foster child taking multiple antidepressants could experience serotonin syndrome, which can be life‑threatening and can cause symptoms including high fever, seizures, irregular heartbeat, and unconsciousness.
Nevertheless, when we reviewed the case files for 80 foster children, we found that 11 (14 percent) were authorized to simultaneously take multiple psychotropic medications within the same drug class during our audit period. As shown in Table 4, five of the foster children whose cases files we reviewed were authorized by the courts or their parents to simultaneously take multiple psychotropic medications within the same class even after the State released its guidelines. All five of these cases were from Riverside and Sonoma counties, which have yet to adopt the state guidelines. Further, none of these five case files contained any documentation demonstrating that the counties followed up with providers to question the need for simultaneously prescribing multiple psychotropic medications from the same class.
The juvenile court in Riverside County authorized the prescriptions in three of these cases, while parents consented to prescriptions for Sonoma County foster children in the other two cases. In one of these cases, a teenaged foster child in Riverside County was prescribed three psychotropic medications at the same time: two antidepressants and a mood stabilizer. In another case, a teenaged foster child in Sonoma County was prescribed two antipsychotics concurrently, which studies have called out as a potentially dangerous combination that should generally be avoided.
| COUNTY | AT LEAST ONE INSTANCE WHERE PRESCRIPTIONS EXCEEDED GUIDELINES FOR NUMBER OF PSYCHOTROPIC MEDICATIONS WITHIN SAME CLASS | |
|---|---|---|
| BEFORE THE STATE PUBLISHED GUIDELINES | AFTER THE STATE PUBLISHED GUIDELINES | |
| Los Angeles | 0/20 cases | 0/20 cases |
| Madera | 1/20 | 0/20 |
| Riverside | 2/20 | 3/20 |
| Sonoma | 7/20 | 2/20 |
| Totals | 10/80 cases | 5/80 cases |
| 13% | 6% | |
Source: California State Auditor’s analysis of records at county welfare services and behavioral health departments.
* We identified four cases in which foster children were prescribed numbers of psychotropic medications that exceeded the State’s recommended guidelines both before and after the State adopted those guidelines. Therefore, a total of 11 (14 percent) of the 80 foster children whose case files we reviewed were authorized to simultaneously take multiple medications within the same drug classification during our audit period.
Four of these five children had also been authorized to take multiple medications before the State adopted its guidelines. Including these four children, we found a total of 10 foster children who were authorized to take multiple medications before the state guidelines took effect. Seven of these children lived in Sonoma County. For three of these children, we did not see any evidence that Sonoma county staff followed up with providers to verify that the concurrent medications were medically necessary before they forwarded the requests to the Superior Court of California, County of Sonoma (Sonoma County Court) for approval. For example, in one of these cases, a foster child was prescribed five different psychotropic medications at the same time, two of which were antipsychotics, yet we did not see any evidence that the county questioned the prescriber on the need to prescribe two antipsychotic medications simultaneously. In the other four instances, the Sonoma County Court delegated to the children’s parent(s) the authority to approve their psychotropic medications. Since Sonoma County does not have a process for reviewing prescriptions that parents authorize, it did not follow up with the prescribers in these cases.
According to a program manager in the Children’s Division, Sonoma County plans to expand its current review process—which we described previously—to include prescriptions authorized by parental consent in the future. In addition, similar to the county’s current process for advising the court about the appropriateness of proposed psychotropic medications, the reviewing psychiatrist should provide these parent(s) an opinion on the efficacy and appropriateness of proposed medications so that they are able to make a more informed decision about whether to approve these medications for their children. It is imperative that Sonoma County make this change as soon as possible because the state data for fiscal year 2014–15 indicates that more than 20 percent of Sonoma County’s foster children receive parental consent to take psychotropic medications. In contrast, less than 1 percent of Los Angeles, Madera, and Riverside counties’ foster children receive parental consent to take these medications. Further, a deputy director at Social Services stated that foster children should receive the same level of oversight from the county with regard to their psychotropic medications whether a court or parent authorizes the medication.
As discussed previously, LA Juvenile Court Services’ staff use guidelines that are nearly identical to the state guidelines to oversee proposed psychotropic medications that require court authorization. This is the likely reason that we did not note any instances in the cases we reviewed in which Los Angeles County did not follow up with providers who prescribed foster children multiple medications in the same class. Similarly, we only noted one instance in which a court authorized a Madera County foster child to take multiple medications in the same classification without evidence that the county followed up with the provider, and this instance occurred before the State issued its guidelines, which Madera subsequently adopted.
As shown in Table 5, the state data indicate that of the 9,317 foster children with filled psychotropic medication prescriptions statewide in fiscal year 2014–15, 851 were prescribed multiple antidepressants at the same time; 330 were prescribed multiple antipsychotics at the same time; and 193 were prescribed multiple stimulants at the same time.7 The state data show that a lower percentage of foster children in Los Angeles County who were prescribed psychotropic medications received multiple medications from the same class than the statewide average, likely reflecting the fact that this county adopted the state guidelines. Conversely, the statewide data indicate that a greater proportion of Sonoma and Riverside county’s foster children who were prescribed psychotropic medications were concurrently prescribed multiple antidepressants compared to the statewide average. For example, nearly 18 percent of Sonoma County’s foster children prescribed psychotropic medications received multiple antidepressants at the same time, which is nearly double the statewide average of 9 percent. Similarly, Riverside County’s percentage of foster children with filled prescriptions for more than one antidepressant at the same time was nearly 12 percent, which is also greater than the statewide average.
As discussed earlier, the Judicial Council recently adopted new and revised forms to request court authorization of psychotropic medications for foster children. These forms now require physicians to describe why they prescribed more than one psychotropic medication in a class for the child. County staff can use this information to better ensure that foster children were properly prescribed psychotropic medications.
| TOTAL NUMBER OF FOSTER CHILDREN WITH FILLED PSYCHOTROPIC MEDICATION PRESCRIPTIONS | FOSTER CHILDREN WITH MORE THAN ONE FILLED ANTIDEPRESSANT PRESCRIPTION* | FOSTER CHILDREN WITH MORE THAN ONE FILLED ANTIPSYCHOTIC PRESCRIPTION* | FOSTER CHILDREN WITH MORE THAN ONE FILLED STIMULANT PRESCRIPTION | ||||
|---|---|---|---|---|---|---|---|
| NUMBER | PERCENT | NUMBER | PERCENT | NUMBER | PERCENT | ||
| Statewide | 9,317 | 851 | 9.1% | 330 | 3.5% | 193 | 2.1% |
| Counties We Visited | |||||||
| Los Angeles | 3,194 | 267 | 8.4% | 69 | 2.2% | 42 | 1.3% |
| Madera | 21 | † | † | † | † | † | † |
| Riverside | 595 | 71 | 11.9 | 26 | 4.4 | † | † |
| Sonoma | 140 | 25 | 17.9 | † | † | † | † |
Sources: California State Auditor’s analysis of data obtained from the Department of Health Care Services’ California Medicaid Management Information System, data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System, and matched Medi‑Cal pharmacy data.
Note: The term foster children refers to children aged zero to 17 in the foster care system.
* For our analysis, we considered foster children to be on more than one psychotropic medication only if they had filled prescriptions for more than one psychotropic medication within the same medication classification for more than 30 consecutive days.
† To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services.
Ten Percent of Foster Children We Reviewed Were Authorized to Receive More Psychotropic Medications Than State Guidelines Recommend for Children Their Ages
Our review also found that some counties did not follow up with prescribers to ensure that foster children only received psychotropic medications that were appropriate for children of their ages. As explained in the Introduction, state guidelines recommend that children five years old or younger take no more than one psychotropic medication at a time, children aged 6 to 11 take no more than two medications, and children aged 12 to 17 take no more than three medications.
However, as shown in Table 6, eight (10 percent) of the 80 foster children whose case files we reviewed had been authorized to take more psychotropic medications than the state guidelines recommended for their ages, yet the counties did not appear to have sought additional justification from the prescribers. By not questioning providers requesting psychotropic medications beyond the guidelines, counties cannot ensure that foster children are taking a number of psychotropic medications that are safe and appropriate for their age.
| COUNTY | AT LEAST ONE INSTANCE WHERE PRESCRIPTIONS EXCEEDED GUIDELINES FOR TOTAL NUMBER OF PSYCHOTROPIC MEDICATIONS BY AGE | |
|---|---|---|
| BEFORE THE STATE PUBLISHED GUIDELINES | AFTER THE STATE PUBLISHED GUIDELINES | |
| Los Angeles | 2/20 cases | 0/20 cases |
| Madera | 0/20 | 0/20 |
| Riverside | 2/20 | 0/20 |
| Sonoma | 4/20 | 1/20 |
| Totals | 8/80 cases | 1/80 cases |
| 10% | 1% | |
Source: California State Auditor’s analysis of records at county welfare services and behavioral health departments.
* We identified one case in which a child was prescribed psychotropic medications that exceeded the State’s recommended guidelines both before and after the State adopted those guidelines. Therefore, eight (10 percent) of the 80 children whose case files we reviewed were authorized to take more psychotropic medications than state guidelines recommend for their ages.
These eight cases all occurred before the issuance of the state guidelines. Four of these eight cases were Sonoma County foster children, three of whom received their parents’ approval to take these medications. In fact, one of these Sonoma County foster children had parental authorization to take these medications both before and after the State issued its guidelines. After the State issued its guidelines, the parents authorized this teenaged foster child to take five psychotropic medications at the same time, although state guidelines recommend children that age should receive no more than three.
In two of the eight cases, Los Angeles County courts authorized foster children to take a number of psychotropic medications that exceeded the state guidelines for their ages. However, these two instances occurred before the State released its guidelines, and neither involved prescriptions that exceeded Los Angeles County’s guidelines. In one of these cases, a young foster child was prescribed three psychotropic medications at the same time. Although the state guidelines would later recommend that foster children aged 6 to 11 only receive up to two psychotropic medications concurrently, Los Angeles County’s guidelines allow children aged 9 to 17 to receive up to three of these medications. In the second case, a teenaged Los Angeles foster child was prescribed four psychotropic medications concurrently. However, one of the four medications was Cogentin, which Los Angeles County’s guidelines do not count toward the maximum number of psychotropic medications.8
The state data show that a significant number of children statewide also had filled psychotropic medication prescriptions that exceeded the recommendations in the state guidelines for their ages. As shown in Table 7, the state data indicate that 29 foster children aged zero to 5 received more than one filled psychotropic medication prescription at the same time during fiscal year 2014–15. Furthermore, the state data show that 159 foster children aged 6 to 11 received more than two filled psychotropic medication prescriptions and that 90 foster children aged 12 to 17 received more than three filled psychotropic medication prescriptions at the same time.
Los Angeles County’s statistics, shown in Table 7, were lower than the corresponding statewide averages while Riverside County’s statistics were higher. Specifically, less than half a percent of Los Angeles County’s foster children aged 12 to 17 receiving psychotropic medication prescriptions had more than three of these medications. Conversely, the rate in Riverside County for foster children the same age was 1.8 percent, or nearly double the statewide average. As discussed previously, Los Angeles County uses guidelines that include age‑based restrictions on psychotropic medications that are very similar to the state guidelines, while Riverside County does not. This likely explains why Los Angeles County’s statistics compare more favorably than Riverside County’s statistics to the statewide average.
| TOTAL NUMBER OF FOSTER CHILDREN WITH FILLED PSYCHOTROPIC MEDICATION PRESCRIPTIONS | FOSTER CHILDREN AGE 0–5 WITH MORE THAN ONE FILLED PSYCHOTROPIC MEDICATION PRESCRIPTIONS | FOSTER CHILDREN AGE 6–11 WITH MORE THAN ONE FILLED PSYCHOTROPIC MEDICATION PRESCRIPTIONS | FOSTER CHILDREN AGE 12–17 WITH MORE THAN ONE FILLED PSYCHOTROPIC MEDICATION PRESCRIPTIONS | ||||||
|---|---|---|---|---|---|---|---|---|---|
| NUMBER | PERCENT | NUMBER | PERCENT | ||||||
| Statewide | 9,317 | 29 | 159 | 1.7% | 90 | 1.0% | |||
| Counties We Visited | |||||||||
| Los Angeles | 3,194 | † | 34 | 1.1% | 14 | 0.4% | |||
| Madera | 21 | † | † | † | † | † | |||
| Riverside | 595 | † | † | † | 11 | 1.8 | |||
| Sonoma | 140 | † | † | † | † | † | |||
Sources: California State Auditor’s analysis of data obtained from the Department of Health Care Services’ California Medicaid Management Information System, data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System, and matched Medi‑Cal pharmacy data.
Notes: State guidelines recommend that children aged zero to 5 take no more than one psychotropic medication, children aged 6 to 11 take no more than two psychotropics medications, and children aged 12 to 17 take no more than three psychotropic medications.
The term foster children refers to children aged zero to 17 in the foster care system.
* For our analysis, we considered foster children to be on more than one psychotropic medication only if they had filled prescriptions for more than one psychotropic medication within the same medication classification for more than 30 consecutive days.
† To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services.
Nearly a Quarter of the Foster Children We Reviewed Were Authorized to Take Larger Dosages of Psychotropic Medications Than State Guidelines Recommend
Our review of 80 case files found that many foster children were authorized to take psychotropic medications in dosages that exceeded the state guidelines without the counties’ adequately documenting that they had contacted the prescribers. As described previously, when Social Services and Health Care Services created the state guidelines, they adopted Los Angeles County’s dosage parameters. These dosage parameters established maximum daily dosages for commonly prescribed psychotropic medications.
However, as shown in Table 8, our review of the case files for 80 foster children identified 18 foster children (23 percent) for whom the courts or their parents approved at least one psychotropic medication with a maximum daily dosage that exceeded the state guidelines. Ten of these children were authorized to take these medications before the State issued its guidelines. One of these 10 children, along with eight more children, were all authorized to take these medications after the State released its guidelines. We found no evidence in any of these cases that the counties identified these prescriptions as potential problems and questioned the prescribers about the dosages.
| COUNTY | AT LEAST ONE PRESCRIPTION EXCEEDED GUIDELINES FOR MAXIMUM DAILY DOSAGE | |
|---|---|---|
| BEFORE THE STATE PUBLISHED GUIDELINES | AFTER THE STATE PUBLISHED GUIDELINES | |
| Los Angeles | 0/20 cases | 6/20 cases |
| Madera | 1/20 | 1/20 |
| Riverside | 5/20 | 0/20 |
| Sonoma | 4/20 | 2/20 |
| Totals | 10/80 cases | 9/80 cases |
| 13% | 11% | |
Source: California State Auditor’s analysis of county records at county welfare services and behavioral health departments.
* Because Los Angeles County used the same parameters before the State adopted them, we consider all Los Angeles County dosage issues as post‑guidelines regardless of when they happened.
† Of these nine cases that exceeded the State’s recommended guidelines (state guidelines), one case also occurred before the the state guidelines. Therefore, 18 (23 percent) of the 80 foster children whose case files we reviewed were authorized to take psychotropic medications with maximum daily dosages that exceeded the state guidelines.
Although Social Services and Health Care Services consider the state guidelines to be best practices, they are of little value if counties do not use them. For example, six of the nine cases that occurred after the issuance of the state guidelines involved foster children in Los Angeles County. We find this surprising since the State adopted Los Angeles County’s preexisting dosage standards as part of the state guidelines. In one of these instances, a physician prescribed an antidepressant medication for a foster child with a maximum daily dosage of 30 milligrams, which is 50 percent higher than the state guidelines’ maximum recommended dosage of 20 milligrams. When we asked the medical director of LA Juvenile Court Services in Los Angeles’ County’s Department of Mental Health why county staff did not follow up with this provider, he explained that the county’s practice has been to only review the actual daily dosage rather than the maximum daily dosage. However, he stated that county staff plan to monitor each prescription’s maximum daily dosage moving forward.
Because a prescriber may include both an actual daily dosage and a maximum daily dosage when seeking court or parental authorization for a prescription, we are aware that some of the foster children we identified in our review may not have taken psychotropic medications in dosages that exceeded the state guidelines. However, we believe counties should question prescribers when they request maximum daily dosages that exceed the state guidelines because they may then choose to increase the children’s dosage amounts up to the authorized maximum amounts without receiving additional review from the counties, the courts, or the children’s parents.
Neither we nor the State can determine the extent statewide to which foster children’s maximum daily dosages may exceed the state guidelines because the State does not capture data related to the maximum daily dosages of psychotropic medications that foster children are authorized to take. However, we believe it would be beneficial for the State to capture such information and compare it to the state guidelines. For example, such an analysis would allow the State to identify counties in which high proportions of foster children are being prescribed psychotropic medications in maximum daily dosages that exceed the state guidelines. This information would also allow the State to identify potentially problematic prescribing patterns so that it could follow up with the relevant counties. As discussed earlier, the Judicial Council recently adopted new and revised forms to request court authorization of psychotropic medications for foster children. These forms now require physicians to describe why they prescribed dosages that were outside the approved range. County staff can use this information to better ensure that foster children were properly prescribed psychotropic medications.
Because the State lacks data on foster children’s maximum authorized daily dosages of psychotropic medications, we compared the statewide data on prescribed daily dosages to the state guidelines’ maximum dosage parameters. The state data show that in fiscal year 2014–15, 523 foster children had 2,389 prescriptions for psychotropic medications with prescribed daily dosages that exceeded the maximum allowable dosages in the state guidelines. These prescriptions represent nearly 2.5 percent of the 95,748 psychotropic medication prescriptions for that year. Although these numbers are fairly small, they indicate that some foster children received psychotropic medications in doses that exceeded the State’s recommended maximum daily dosages, which put these children at higher risk of potentially dangerous side effects.
A Significant Number of the Foster Children We Reviewed Who Were Prescribed New Psychotropic Medications Did Not Receive Timely Follow‑Up Visits With Prescribers or Other Health Care Providers
Our review of the 80 case files found that one‑third of the foster children who were prescribed new psychotropic medications did not receive follow‑up care with prescribers or other health care providers in a timely manner. Specifically, the academy guidelines state that providers should follow up with patients ideally within two weeks, but at least within a month, after they start psychotropic medications. Follow‑up visits within 30 days are critical because adverse side effects from these medications are most common during the initial trial period. We excluded 13 cases from our analysis of follow‑up visits because the foster children had been authorized to start all of their psychotropic medications before the start of our audit period. However, as Table 9 shows, we found no evidence in the county case files or the state data that one‑third of the remaining 67 children had follow‑up visits with their prescribers or other health care providers within 30 days of filling their prescriptions for psychotropic medication or receiving authorization to do so.9
| COUNTY | NO EVIDENCE THAT PROVIDERS FOLLOWED UP WITHIN 30 DAYS AFTER A FOSTER CHILD STARTED A PSYCHOTROPIC MEDICATION |
|---|---|
| Los Angeles | 2/16 cases |
| Madera | 8/20 |
| Riverside | 7/19 |
| Sonoma | 6/12 |
| Total | 23/67 cases |
| 34% |
Sources: California State Auditor’s analysis of county records at welfare services and behavioral health departments, as well as data obtained from the Department of Health Care Services’ Paid Claims and Encounters System.
Note: We excluded 13 cases from our analysis of follow‑up visits because, in those cases, the foster children were authorized to start all of their psychotropic medications before our audit period. As a result, the foster children may have received follow‑up appointments before the audit period.
One case in which a foster child did, in fact, have a follow‑up meeting with a psychiatrist within 30 days of starting a higher dose of a psychotropic medication illustrates the importance of timely follow‑up visits. About three weeks after starting the higher dose of the medication, the child complained of shaking hands and chest pain; on the advice of another doctor, the child stopped taking the medication. When the psychiatrist who had increased the medication dosage met with the foster child within 30 days as the academy guidelines recommend, the psychiatrist determined that the child’s symptoms had greatly worsened since the child stopped taking the medication. In response, the psychiatrist restarted the child’s medication but at a lower dosage. If this follow‑up visit had not occurred or had been delayed, this child might have experienced worsening symptoms as a result of discontinuing the medication.
Three of the four counties we visited offered similar explanations for the fact that so many foster children did not receive timely follow‑up care. For example, a division chief in Los Angeles County’s Department of Children and Family Services indicated that the department supports follow‑up appointments with providers within 30 days (or sooner, if indicated) for all foster children on psychotropic medications. However, she also noted that the limited number of child psychiatrists who accept Medi‑Cal‑insured clients may explain why some foster children did not receive a follow‑up visit with their prescriber within 30 days of starting their medication. Similarly, a division manager within Madera County Behavioral Health Services noted that the limited number of child and adolescent psychiatrists make it difficult for small counties to schedule follow‑up visits with these prescribers. The Sonoma County Behavioral Health Division’s medical director also agreed that it is reasonable for psychiatrists to arrange follow‑up visits within 30 days of foster children's starting psychotropic medications and stated that the county is in the process of revising its policies to adhere to the academy guidelines as closely as possible.
On the other hand, Riverside County Behavioral Health’s medical director stated that child and adolescent psychiatrists are trained extensively in their field and that the county defers to the individual prescriber’s discretion regarding any follow‑up on a foster child’s medications. However, we believe that counties that defer to individual providers are missing an opportunity to better protect the foster children under their care. Unless counties ensure that all foster children who start new psychotropic medications receive follow‑up visits with their prescribers within 30 days, they cannot be certain that the prescribers will monitor the children for potential adverse side effects.
The state data show that the lack of appropriate follow‑up care appears to be a statewide problem. As Table 10 illustrates, 1,881 (29 percent) of the 6,471 foster children statewide had filled prescriptions for a new psychotropic medication in fiscal year 2013–14 without a corresponding Medi‑Cal claim for a follow‑up service within 30 days after the prescription was filled. We acknowledge that in some of these cases, the foster child may not have shown up for a scheduled follow‑up appointment. The state data show that Los Angeles County had follow‑up appointment rates that were better than the statewide statistics by 14 percentage points. They also indicate that 41 and 51 percent of the foster children in Riverside and Sonoma counties who had a filled prescription for a new psychotropic medication did not have a corresponding Medi‑Cal claim for a follow‑up service within 30 days after the prescription was filled. Further, although the state data show that the rate of foster children who had a filled prescription for a new psychotropic medication without a corresponding follow‑up medication service within 30 days after the prescription was filled is 29 percent throughout the state, 15 of the counties referred to in Table A‑8 in the Appendix had rates that exceeded 50 percent. However, the state data only cover services provided through Medi‑Cal, and some of the children may have received follow‑up services outside of Medi‑Cal. We discuss this issue further in Chapter 2.
As discussed earlier, the Judicial Council recently adopted new and revised forms to request court authorization of psychotropic medications for foster children. These forms now require county staff to list the dates of all medication management appointments since the last court hearing. County staff can use this information to better ensure that foster children were properly prescribed psychotropic medications.
| NUMBER OF FOSTER CHILDREN WITH NEW PSYCHOTROPIC MEDICATION PRESCRIPTIONS* |
NUMBER OF FOSTER CHILDREN WITHOUT A FOLLOW‑UP MEDICATION SERVICE WITHIN 30 DAYS OF FILLING AT LEAST ONE NEW PSYCHOTROPIC MEDICATION PRESCRIPTION |
||||||
|---|---|---|---|---|---|---|---|
| NUMBER | PERCENT | ||||||
| Statewide | 6,471 | 1,881 | 29.1% | ||||
| Counties We Visited | |||||||
| Los Angeles | 2,252 | 334 | 14.8% | ||||
| Madera | 17 | † | † | ||||
| Riverside | 406 | 167 | 41.1 | ||||
| Sonoma | 90 | 46 | 51.1 | ||||
Sources: California State Auditor’s analysis of data obtained from the Department of Health Care Services’ Paid Claims and Encounters System, data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System, and matched Medi‑Cal pharmacy data.
Note: The term foster children refers to children aged zero to 17 in the foster care system.
* We defined a new prescription as any prescription for a psychotropic medication that the child had not been prescribed in the prior 120 days and, as discussed in the Scope and Methodology section, we applied the National Committee for Quality Assurance's methodology for follow‑up care.
† To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services.
Many of the State’s Foster Children Who Were Prescribed Psychotropic Medications May Not Have Received Corresponding Psychosocial Services
Both the academy and state guidelines emphasize the importance of providing foster children with alternative treatments in addition to psychotropic medications. Specifically, the academy guidelines point out that, while many youth benefit from psychotropic medications used as part of a comprehensive treatment plan, this plan should include nonmedication interventions as well, if appropriate. In fact, the academy guidelines caution that medication may be overprescribed when insufficient attention is paid to other supports and services, such as psychosocial treatments.10 The academy guidelines also state that actively pursuing alternative interventions is especially important when the medications can have serious side effects and are prescribed over an extended period of time. Similarly, the state guidelines indicate that psychotropic medications should be used in conjunction with psychosocial services. According to the state guidelines, the only exception is when a health care provider terminates a child’s psychosocial services because they have been effective but the provider determines that the continued use of medication is necessary to prevent the recurrence of symptoms.
Traditionally, psychosocial services are recommended before pharmacological treatment. However, the academy guidelines acknowledge that pharmacological treatments can be initiated before, concurrent with, or after psychosocial services, depending on the available research evidence and needs of the patient. For example, randomized controlled trials suggest that medication management for attention‑deficit/hyperactivity disorder should be the first‑line treatment, while medication combined with behavioral treatment may be necessary for optimal outcomes for a child with more complex problems. Conversely, for obsessive‑compulsive disorder, the best first option is either cognitive‑behavioral therapy, especially if delivered by an expert psychotherapist, or combined treatment (i.e., therapy and medication). However, the academy guidelines also note that although empirically supported psychosocial treatments may be the optimal first step for many disorders, many communities lack skilled providers of such treatments. In these communities, starting treatment with medication may be the best intervention available.
Despite the importance of psychosocial services to children’s overall treatment plans, we found that many foster children may not have received such services before and after starting psychotropic medications. We reviewed the case files of 67 foster children at the four counties we visited to determine whether they received psychosocial services before and after starting new psychotropic medications. Because the foster children may have received psychosocial services that the counties did not adequately document in their case files, we also analyzed the State’s Medi‑Cal data for these children to determine whether the Medi‑Cal program paid for their psychosocial services. As Table 11 illustrates, our analysis found that between 9 and 15 percent of the 67 foster children did not receive psychosocial services six months before starting psychotropic medications. Furthermore, this evidence also indicates that between 4 and 7 percent of the 67 foster children did not receive psychosocial services within six months after starting medications.
| NO PSYCHOSOCIAL SERVICES WITHIN 6 MONTHS... | OF THOSE CASES THAT RECEIVED PSYCHOSOCIAL SERVICES WITHIN 6 MONTHS... | |||
|---|---|---|---|---|
| ...BEFORE STARTING AT LEAST ONE PSYCHOTROPIC MEDICATION, BASED ON COUNTY RECORDS AND STATE DATA | ...AFTER STARTING AT LEAST ONE PSYCHOTROPIC MEDICATION, BASED ON COUNTY RECORDS AND STATE DATA | ...BEFORE, THE NUMNBER THAT DID NOT RECEIVE THOSE SERVICES WITHIN 30 DAYS BEFORE STARTING AT LEAST ONE MEDICATION BASED ON COUNTY RECORDS AND STATE DATA | ...AFTER, THE NUMNBER THAT DID NOT RECEIVE THOSE SERVICES WITHIN 30 DAYS AFTER STARTING AT LEAST ONE MEDICATION BASED ON COUNTY RECORDS AND STATE DATA | |
| Los Angeles | 1/16–2/16 cases | 0/16–1/16 cases | 0/15–1/14 cases | 0/16–0/15 cases |
| Madera | 3/20–4/20 | 0/20 | 4/17–5/16 | 7/20–8/20 |
| Riverside | 1/19–2/19 | 1/19–2/19 | 3/18–4/17 | 3/18–4/17 |
| Sonoma | 1/12–2/12 | 2/12 | 4/11–3/10 | 4/10 |
| Totals | 6/67–10/67 cases* | 3/67–5/67 cases* | 11/61–13/57 cases† | 14/64–16/62 cases‡ |
| 9–15 percent | 4–7 percent | 18–23 percent | 22–26 percent | |
Sources: California State Auditor’s analysis of county records at welfare services and behavioral health departments, as well as data obtained from the Department of Health Care Services’ Paid Claims and Encounters System.
Note: As described here, we report a range in the number of foster children who did not receive timely psychosocial services because of differences in the procedure codes used by the National Committee for Quality Assurance and the Department of Health Care Services to identify psychosocial services.
* We excluded 13 cases from these analyses because, in those cases, the foster children were authorized to start all of their psychotropic medications before our audit period. Therefore, the services may have occurred outside the audit period and we did not review the documentation.
† We excluded a number of cases from this analysis because the foster children were either authorized to start all of their psychotropic medications before our audit period or because the foster children did not have psychosocial services within six months before starting at least one of their psychotropic medications.
‡ We excluded a number of cases from this analysis because the foster children were either authorized to start all of their psychotropic medications before our audit period or because the foster children did not have psychosocial services within six months after starting at least one of their psychotropic medications.
In addition, counties may not be ensuring that foster children receive the optimal care if those children do not promptly receive the necessary psychosocial services. We evaluated whether the foster children whose files we reviewed received services within 30 days of starting psychotropic medications. As Table 11 shows, of the foster children who had received psychosocial services within the six months before starting psychotropic medications and who started at least one psychotropic medication within our audit period, we found that between 18 and 23 percent did not receive these psychosocial services within 30 days before starting their medications. Of the foster children who received psychosocial services within six months after starting medications and who started at least one psychotropic medication within our audit period, the evidence suggests that between 22 and 26 percent did not receive those services within the first 30 days of starting the medications.
When we reviewed the state data to determine the extent to which foster children statewide who had a filled prescription for psychotropic medications also received supporting psychosocial services, we found that between 3,965 and 7,489 (41 to 77 percent) of the 9,707 foster children with paid prescriptions for psychotropic medications in fiscal year 2013–14 did not receive corresponding psychosocial services through Medi‑Cal both 30 days before and 30 days after receiving psychotropic medications, as shown in Table 12.11 Additionally, although not shown in the table, the state data show that of the 5,163 foster children who did obtain mental health services, 57 percent did not receive these services both 30 days before and after filling new psychotropic medication prescriptions.
| FOSTER CHILDREN WITH FILLED PRESCRIPTIONS FOR PSYCHOTROPIC MEDICATIONS |
NUMBER OF FOSTER CHILDREN WITH AT LEAST ONE INSTANCE OF NO SERVICE WITHIN... |
||||||
|---|---|---|---|---|---|---|---|
| ...30 DAYS, BEFORE AND AFTER, OF FILLING A PRESCRIPTION (NOT INCLUDING COMMUNITY SUPPORT SERVICES) |
...180 DAYS, BEFORE AND AFTER, OF FILLING A PRESCRIPTION (NOT INCLUDING COMMUNITY SUPPORT SERVICES) |
||||||
| Statewide | 9,707 | 7,499 | 4,544 | ||||
| Counties We Visited | |||||||
| Los Angeles | 3,267 | 2,185 | 997 | ||||
| Madera | 21 | * | * | ||||
| Riverside | 600 | 556 | 363 | ||||
| Sonoma | 142 | 134 | 98 | ||||
Sources: California State Auditor’s analysis of data obtained from the Department of Health Care Services’ Paid Claims and Encounters System, data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System, and matched Medi‑Cal pharmacy data.
Notes: The term foster children refers to children aged zero to 17 in the foster care system.
In addition, as described below, we report a range in the number of foster children who did not receive timely psychosocial services because of differences in the procedure codes used by the National Committee for Quality Assurance and the Department of Health Care Services to identify psychosocial services.
* To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services.
We report a range in the number of foster children who did not receive psychosocial services because of differences in the way psychosocial services are identified in the state data. We based the high estimate in our range on the definition of psychosocial services contained in the Healthcare Effectiveness Data and Information Set (HEDIS), a set of health care performance measures developed by the National Committee for Quality Assurance and used by more than 90 percent of the health care plans in the United States. However, Health Care Services uses an expanded version of the HEDIS definition of psychosocial services—which includes services provided by certain mental health professionals and billed as comprehensive community support services or provided at federally qualified health centers or rural health clinics—which is reflected in the low estimate in our range. The chief medical information officer of Health Care Services noted that the HEDIS definition does not count community support services as psychosocial services. However, she stated that mental health professionals such as psychiatrists and licensed clinical social workers provide most of the community support services in California and should therefore be counted as a psychosocial service. Further, the services provided at federally qualified health centers or rural health clinics that Health Care Services includes in its definition are provided by this same group of mental health professionals. Consequently, our analysis estimates the likely range in which foster children who took psychotropic medications also received psychosocial services through the Medi‑Cal program based on both the HEDIS and Health Care Services' definition of psychosocial services.
In addition, the state data used in our analysis only include those services for which Medi‑Cal paid and does not include services paid for outside of Medi‑Cal. Further, although children may enter and exit the foster care system on multiple occasions over time, we did not adjust our calculations to account for this. Information from the California Child Welfare Indicators Project for 2013 indicated that 75 percent of foster children had lengths of stay in their last foster care placement of 7.7 months or longer.12
Finally, as discussed earlier, the Judicial Council adopted new and revised forms to request court authorization of psychotropic medications for foster children. These forms place an increased emphasis on the provision of psychosocial services to these children. For example, the forms now require prescribing physicians to provide more detailed information about the psychosocial services foster children previously received. In addition, the forms now require social workers and probation officers to identify the specific psychosocial services that foster children received in the past six months, as well as to indicate the types of therapeutic services the children are enrolled in or are recommended to participate in during the next six months.
Although the Judicial Council’s changes to the court authorization forms place increased emphasis on the psychosocial services provided to foster children, we believe additional steps are necessary. Specifically, counties must develop and implement stronger procedures to ensure that foster children who are prescribed psychotropic medications consistently receive corresponding psychosocial services. In addition, the counties must adequately document these services so that caregivers can better monitor the children, as we will discuss in further detail in Chapter 2.
In Violation of State Law, More Than a Third of the Foster Children We Reviewed Received At Least One Prescription for Psychotropic Medications Without Required Court Approval or Parental Consent
Information Required With Applications for Court Authorization to Administer Psychotropic Medications
- A description of the child’s psychiatric diagnosis to be treated with the medication.
- The proposed medication to be administered along with a maximum daily dosage and length of time for the course of treatment.
- The anticipated benefits and possible side effects associated with using the medication.
- A list of any other drugs that the child is currently taking and a description of any effect these drugs may produce in combination with the psychotropic medication.
- A description of any other therapeutic services related to the child’s mental health status.
- A statement that the child has been informed in an age‑appropriate manner of the recommended course of treatment, the basis for it, and its possible results, along with the child’s response to the information.
Source: California Rules of Court, Rule 5.640, in effect before July 2016 for the period covered by our testing.
Counties do not always obtain required court or parental approval before foster children receive psychotropic medications. As previously discussed, state law requires that juvenile courts either authorize the administration of psychotropic medications for foster children or delegate that authority to the children’s parents upon findings on the record that the parents pose no danger to the children and have the capacity to authorize psychotropic medications. Although California rules of court allow for the administration of psychotropic medications without prior court authorization in emergency situations, even in emergency situations physicians must seek authorization no more than two "court days" after administering the medications.
A physician seeking court authorization to prescribe a psychotropic medication to a foster child must submit the application forms developed by the Judicial Council for that purpose. As shown in the text box, the application must include a number of items to help the court decide how to adjudicate the request. A parent or guardian, or others as allowed by the court’s rules, may file an opposition to the request with the court. Based on the information in the application and any opposition to the request, the court may grant authorization without a hearing. Alternatively, it can schedule a hearing, at which it may grant, deny, or modify the application. At that time, it may also set a date for review of the child’s progress and condition. A court order to authorize a psychotropic medication is effective for 180 days unless the court terminates or modifies it sooner.
However, when we reviewed the 80 case files we selected, we found that more than a third of the foster children had at least one prescription for psychotropic medications without court authorization or parental consent. Specifically, 23 (34 percent) of the case files of the 67 foster children who should not have received psychotropic medications without court approval lacked evidence of such approval for at least one of the psychotropic medications that the child was prescribed, as shown by Table 13. For example, we identified one foster child who was prescribed both an antipsychotic medication and an antidepressant medication without receiving prior court approval. Further, five (38 percent) of the case files for 13 foster children who should have received parental consent before taking psychotropic medications lacked evidence of consent for at least one of the psychotropic medications prescribed for the child. In fact, one of these case files did not contain evidence of parental consent for six of the child’s psychotropic medications.
| COUNTY | NO DOCUMENTATION OF COURT AUTHORIZATION FOR AT LEAST ONE PSYCHOTROPIC MEDICATION PRESCRIPTION | NO DOCUMENTATION OF PARENTAL CONSENTS FOR AT LEAST ONE PSYCHOTROPIC MEDICATION PRESCRIPTION | LATE COURT AUTHORIZATION FOR AT LEAST ONE PSYCHOTROPIC MEDICATION PRESCRIPTION* | PRESCRIPTION FOR PSYCHOTROPIC MEDICATION FILLED PRIOR TO AUTHORIZATION |
|---|---|---|---|---|
| Los Angeles | 8/18 cases | 2/2 cases | 4/18 cases | 2/20 cases |
| Madera | 6/20 | 0/0 | 6/20 | 3/20 |
| Riverside | 6/20 | 0/0 | 7/20 | 3/20 |
| Sonoma | 3/9 | 3/11 | 3/9 | 4/20 |
| Totals | 23/67 cases | 5/13 cases | 20/67 cases | 12/80 cases |
| 36% | 38% | 30% | 15% |
Sources: California State Auditor’s analysis of county records at welfare services and behavioral health departments, as well as data obtained from the Department of Health Care Services’ Paid Claims and Encounters System.
* We defined late court authorizations as either counties not obtaining a renewed court authorization within 180 days for continuing psychotropic medications, or not seeking a court authorization within two court days of the emergency administration of psychotropic medications to a foster child.
Further, we attempted to compile statewide data, however Social Services' data is not formatted in a way that allows us to definitively identify if court authorizations or parental consents are associated with a specific psychotropic medication. As a result, we analyzed the statewide data to identify the frequency with which court authorizations or parental consents existed for any medication and if that consent was either 180 days before or 30 days after the psychotropic medication prescription was filled. As Table 14 illustrates, more than 65 percent of the 9,317 foster children that the state data show as having had paid prescriptions for psychotropic medications in fiscal year 2014–15 were prescribed at least one psychotropic medication for which Social Services’ data system lacks any record of court or parental approval. In fact, more than 3,400 (37 percent) of these children had no court authorization or parental consent recorded in Social Services’ data system for any of their psychotropic medications. These outcomes were even more pronounced at the four counties we reviewed—more than 20 percent to nearly 78 percent of the prescriptions at these counties lacked records of consent. We acknowledge that both the counties’ case files and the state data related to court authorizations and parental consents may be incomplete; in fact, we discuss the deficiencies in the state data in Chapter 2. Nonetheless, our analyses strongly suggest that a sizeable number of foster children were prescribed psychotropic medications without prior court authorization or parental consent.
| TOTAL NUMBER OF FOSTER CHILDREN WITH FILLED PRESCRIPTIONS FOR PSYCHOTROPIC MEDICATIONS | TYPES OF CONSENT | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| COURT AUTHORIZATION OR PARENTAL CONSENT FOR ALL PSYCHOTROPIC MEDICATIONS | NO COURT AUTHORIZATION OR PARENTAL CONSENT FOR ANY PSYCHOTROPIC MEDICATIONS | NO COURT AUTHORIZATION OR PARENTAL CONSENT FOR ONE OR MORE PSYCHOTROPIC MEDICATIONS | ||||||||
| NUMBER | PERCENT | NUMBER | PERCENT | NUMBER | PERCENT | |||||
| Statewide | 9,317 | 3,232 | 34.7% | 3,448 | 37.0% | 6,085 | 65.3% | |||
| Counties We Visited | ||||||||||
| Los Angeles | 3,194 | 920 | 28.8% | 1,475 | 46.2% | 2,274 | 71.2% | |||
| Madera | 21 | * | * | * | * | * | * | |||
| Riverside | 595 | 300 | 50.4 | 121 | 20.3 | 295 | 49.6 | |||
| Sonoma | 140 | 31 | 22.1 | 65 | 46.4 | 109 | 77.9 | |||
Sources: California State Auditor’s analysis of data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System and matched Medi-Cal pharmacy data.
Notes: The term foster children refers to children aged zero to 17 in the foster care system.
* To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services.
We also found that the counties we visited did not always obtain court authorizations for psychotropic medications in a timely manner. As previously mentioned, court authorizations for psychotropic medications are only effective for up to 180 days. For a foster child to continue to receive a psychotropic medication after six months, the county must seek to renew the court’s authorization. Furthermore, a foster child in an emergency situation may take psychotropic medications without an authorization; however, the court must receive a request for authorization within two days after the child starts the medication. If counties do not seek court authorization within two days, the foster child is taking psychotropic medications without proper approval. However, our review of the case files for the 67 children who required court authorization for their psychotropic medications found that 20 (30 percent) contained court authorizations that counties had obtained from 12 days to more than seven months late. In fact, in one case, Madera County renewed the court’s authorization for three of a child’s medications seven months late. In this instance, staff stated that the county opposed one of the proposed medications, and because of delays in the process, the county never followed up to ensure the other requested medications were approved. When counties do not seek to obtain court approvals in a timely manner, they deprive courts of the opportunity to assess whether ongoing psychotropic medications are necessary and safe for foster children to receive.
Moreover, weaknesses in the court and parental authorization processes could lead to foster children receiving psychotropic medications before the prescriptions are approved. For example, as Figure 3 shows, the processes used at the four counties we visited allow providers to write prescriptions for psychotropic medications at the same time they request authorization from the courts or parents. The caregivers of the foster children could then take the prescriptions to pharmacies to be filled. In fact, 12 (15 percent) of 80 case files we reviewed contained instances in which foster children’s caregivers filled their prescriptions before they were authorized. When we asked what mechanisms prevent children from taking their medications without the necessary authorizations, staff at three of the counties asserted that their caregivers are responsible for ensuring that they administer the psychotropic medications only after the prescriptions are authorized. Alternatively, Madera County Social Services’ deputy director stated that he believes social workers are ultimately responsible for ensuring that foster children do not take psychotropic medications that are not yet approved.
Figure 3
Psychotropic Medication Oversight of Children in Foster Care
Sources: California State Auditor’s analysis of state laws and regulations, county policies and procedures, and interviews with county officials at Los Angeles, Madera, Riverside, and Sonoma counties.
Note: We use the term foster children to refer to children aged zero to 17 in the foster care system.
* The court may delegate its authority to administer psychotropic medications to a foster child’s parents, which removes the court authorization process.
† County coordinators include social workers, probation officers, public health nurses, and other county staff who coordinate gathering the court authorization request documents to provide to the courts.
Given the results of our case file review, we believe that better safeguards are necessary to prevent children from taking psychotropic medications without the legally required approvals. For example, counties could create a process in which the caregiver notifies a foster child’s social worker or public health nurse when the child is ready to start a psychotropic medication. The social worker or public health nurse could then determine whether court or parental authorizations exist for the medication, and inform the caregiver about whether the foster child can start the psychotropic medication. This process would also allow counties to obtain more accurate medication start dates, an issue that we discuss in Chapter 2. By ensuring that caregivers know when to properly administer psychotropic medications to their foster children, counties can gain better assurance that foster children do not take psychotropic medications before those prescriptions are approved.
Because most counties we visited identified the caregiver as the point of control in the administration of psychotropic medications to foster children, the entity that oversees the caregivers should logically be responsible for providing instructions related to those medications’ authorization. Social Services’ Community Care Licensing Division—specifically, its Children’s Residential Licensing Program (Licensing Program)—issues licenses to homes and facilities that house foster children and performs inspections of those homes to ensure they provide a safe and healthy environment. The Licensing Program created a medications guide specific to group homes that includes detailed information concerning psychotropic medication use and explains the court authorization process. According to a program manager, the Licensing Program posted this medication guide on its website on December 31, 2015. She indicated that the Licensing Program is currently creating a similar guide for foster family agencies and homes. By issuing clear, detailed instructions to caregivers in all types of facilities, the State can better ensure that foster children do not receive psychotropic medications without or before approval.
Two of the counties we reviewed also recently implemented processes that may help mitigate the issues we found related to missing or late court authorizations. Specifically, in July 2015, Riverside County hired a public health nurse whose primary responsibility is to monitor and ensure compliance with the court authorization process at both a case level and a systemic level. The public health nurse produces a monthly report for Riverside County’s Department of Social Services summarizing the number of court authorizations that have lapsed without renewals. Similarly, in November 2015 Sonoma County started to track expiring court authorizations and parental consents to help ensure foster children have current approvals for psychotropic medications. A program development manager from Sonoma County Family, Youth and Children Division creates monthly summary reports of foster children prescribed psychotropic medications from Social Services’ Child Welfare Service Case Management System and provides the reports to social worker supervisors and their managers for follow up.
Despite Sonoma County’s recent positive steps, we remain concerned about its problematic practices for obtaining parental consent for psychotropic medications. As mentioned earlier, Sonoma County used parental consent far more frequently than most other counties in fiscal year 2014–15. Sonoma County told us that its use of parental consent is in line with its local legal culture to keep parents involved in their children’s lives. Consequently, its social workers generally advocate to the court to delegate authorization of psychotropic medications to the parents. As a result, Social Services’ data show that most counties recorded parental consent for 1 percent or less of their foster children, whereas Sonoma County recorded parental consent for more than 20 percent.
According to a deputy director at Social Services, a county may have valid reasons for having parents consent for a foster child’s psychotropic medications. However, Sonoma County currently does not follow its policy related to obtaining parental consent for psychotropic medications. Specifically, the Sonoma County Family, Youth and Children Division purportedly operates under a 16‑year‑old policy related to parental consent, first adopted in response to the statutes that established the requirement. Among other things, the policy states that social workers will mail parents copies of physician recommendations for medications along with consent forms—a process that would clearly document the request for medications and the parents’ consent. However, according to a Sonoma County division director, the county does not follow this policy. Instead, prescribing physicians must work with the parents directly to obtain their informed consent. This process seems problematic, since it is unclear how physicians would know whom to contact if caregivers bring the children to appointments. Contrary to what the department director indicated, a program manager stated the county’s practice is that social workers obtain parental consent, verbal or otherwise, and then record the consent into Social Services’ data system every six months.
Recommendations
Counties
To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should take the following actions:
• Implement procedures to more closely monitor requests for authorizations for foster children's psychotropic medications that exceed the state guidelines for multiple prescriptions, specific age groups, or dosage amounts. When prescribers request authorizations for prescriptions that exceed the state guidelines, counties should ensure the new court authorization forms contain all required information and, when necessary, follow up with prescribers about the medical necessity of the prescriptions. Counties should also document their follow‑up monitoring in the foster children’s case files. In instances in which counties do not believe that prescribers have adequate justification for exceeding the state guidelines, the counties should relay their concerns and related recommendations to the courts or parents.
• Ensure that all foster children are scheduled to receive a follow‑up appointment within 30 days of starting a new psychotropic medication.
• Implement processes to ensure that foster children receive any needed mental health, psychosocial, behavioral health, or substance abuse services before and concurrently with receiving psychotropic medications.
• Implement a systemic process for ensuring that court authorizations or parental consents are obtained and documented before foster children receive psychotropic medications and that court authorizations for psychotropic medications are renewed within 180 days as state law requires. The process should also ensure that the counties better document the court authorizations and parental consents in the foster children’s case files.
• Develop and implement a process for county staff and caregivers to work together to ensure the psychotropic medications are authorized before being provided to foster children. This process should also ensure that the counties obtain accurate medication start dates from caregivers.
Riverside County
To improve its oversight of foster children who are prescribed psychotropic medications, Riverside County should take the following actions:
• Immediately adopt the state guidelines for its physicians’ use when prescribing psychotropic medications and for the county's use when reviewing court authorization requests.
• Continue to use its new tracking process to better ensure that court authorizations are renewed within 180 days.
Sonoma County
To improve its oversight of foster children prescribed psychotropic medications, Sonoma County should take the following actions:
• Immediately adopt the state guidelines for its physicians’ use when prescribing psychotropic medications and the county’s use when reviewing court authorization requests.
• Within six months, implement a process to review psychotropic medications that receive parental consent rather than court authorization.
• Update its policies to describe methods for obtaining and documenting in the foster children's case files parental consents for psychotropic medications.
California Department of Social Services
To better ensure that counties only use parental consent in place of court authorization when it is appropriate, Social Services should assess Sonoma County’s practice of advocating to the juvenile court that it delegate to parents the authority to administer psychotropic medications to foster children.
To better ensure that all caregivers are informed and educated regarding the use of psychotropic medications and the court authorization process, Social Services should develop instructions regarding these topics and provide them to caregivers, such as foster family agencies, that do not operate group homes.
Footnotes
6 We describe the classifications for psychotropic medications in the Introduction. Go back to text
7 The state guidelines state that the antidepressant trazodone is excepted when prescribed as a hypnotic. Because the state data did not identify when trazodone was prescribed as a hypnotic, we did not exclude it. Go back to text
8 According to the medical director of Los Angeles County’s Juvenile Justice Mental Health Program, the county excluded Cogentin from its standards because it is primarily used to counteract side effects of antipsychotics, not to treat symptoms of a mental or behavioral disorder. The state guidelines do not make an exception for Cogentin in determining the maximum number of medications a child may receive. Go back to text
9 Rather than using the ideal two‑week time frame, we tested whether the foster children had a follow‑up visit with their prescriber or other health care provider within 30 days because we lacked information about the exact dates that the children began taking the medications. Instead, we used the dates the prescriptions were filled or—if we did not have that information—we used the dates on which courts or parents authorized the medications. The 30‑day time frame allows a two‑week buffer in case children did not begin taking the medication immediately after the prescriptions were filled or authorized. Go back to text
10 Psychosocial treatments can include behavioral health counseling and therapy, therapeutic behavioral services, crisis intervention, and services provided in a psychiatric health facility. Go back to text
11 To determine an approximate start date for the psychotropic medications, we used the date the medication was filled at the pharmacy. Go back to text
12 The California Child Welfare Indicators Project is a collaborative venture between the University of California, Berkeley School of Social Work and Social Services that makes available child welfare administrative data to policymakers, child welfare workers, and the public on a website. Go back to text