Psychotropic Medication and Children in Foster Care: Tips for Advocates and Judges

Vol 31 No 2

The federal government is stepping up oversight of psychotropic medication use among children in state foster care.

In light of these developments, legal advocates may question how they can best advocate and make decisions for these children. This article, adapted from a recent ABA practice and policy brief, helps attorneys and judicial officers understand the proper role of psychotropic medications for these children, explains the benefits and drawbacks of medication, and supports a multimodal approach to treating children’s mental health disorders. A list of questions every judge and attorney should ask in cases involving psychotropic medications provides a practical framework for decision making.

Children who enter foster care face many changes and challenges that can lead to mental health disorders treated with psychotropic medications. Many have experienced abuse and neglect. Some have witnessed violence and trauma. Others have parents who suffer profound mental health issues. Regardless of what led to their involvement in the child welfare system, all face separation, broken relationships, and confusion. Increasing their vulnerabilities are risk factors such as poverty, neighborhood violence, exposure to parental mental illness, racial discrimination, lack of food, and homelessness.

The paths to a mental health diagnosis are numerous and complex. Genetically some of these children are already prone to disruptions in their mental health. Mental health disorders such as attention deficit disorder or bipolar disorder, even borderline personality disorder, are thought to have genetic components that place children at risk for developing the same disorders as their parents. Environmental experiences are also linked to mental health issues such as conduct disorder, depression, and anxiety disorder. Exposure to violence is directly linked to post traumatic stress disorder and depression.

The Role of Medication in Healing

For children and teens in foster care who struggle with mental health disorders, the goal is to help them heal and function optimally. Among their needs are to:

  • understand what is happening to them, why they are not living with their parents, and their options.

  • be able to feel their emotions and work through them, but know how to manage them in age-appropriate ways so they do not interfere with their success, growth, and development.

  • be able to communicate with those who advocate for them and make decisions on their behalf.

  • feel stable or organized in their thinking so they can reclaim age-appropriate power and take charge of their lives.

Medications can help children and teens in foster care, but they can also further impair them, derail them, and sabotage them. Without a clear understanding of their mental health issues, misdiagnoses can be made and incorrect medications can be prescribed.

If there is no reliable caregiver who can describe the child’s struggles, information collected can be biased and incomplete. If emotional trauma underlies the presenting symptoms and is not addressed, medications can have no effect or increase problems. If medications are prescribed but other therapies are not provided and supervision of the medication is inadequate, healing and stabilization supporting healthy growth will not occur. Finally, if caregivers are not adequately trained and educated in caring for a child with significant emotional and psychological needs, medications can often be given to the child to “manage their behaviors” rather than to truly treat the child’s illness.

Children and teens also need to be safe. Depression or suicidal thinking must be addressed. Self-abusive behaviors must be contained and risk-taking behaviors reduced. Medications can be part of a successful intervention and treatment plan.

To adequately and successfully represent and speak for a child or teen in foster care, the child’s advocate must be able to communicate with the child and discuss the child’s experiences. Does the child manage his or her acting-out behaviors and emotions, use positive social skills, think clearly, and track the ongoing events in their lives? Working with children and teens in foster care requires a solid understanding of the positive and negative aspects of medication use in this population.

 

Benefits of Psychotropic Medications

Medications make life easier for many children and adults everyday. Medications save lives, relieve pain, manage troublesome symptoms, and help people improve their ability to function in the world. These medications specifically target symptoms and issues associated with mental illness and mental health. 
 

  • Thought disorders, such as schizophrenia, can often be helped by medications such as resperidone (Risperdal), which promotes the ability to think more clearly and function at a higher level.

  • Mood disorders, such as depression, can be helped with medications such as sertraline (Zoloft), which help regulate emotions and address basic issues like sleep and concentration.

  • Behavior disorders, such as conduct disorder, can often be helped with anti-anxiety medications such as atenolol (Tenormin), to help manage aggressive outbursts.

  • Attention disorders, such as attention deficit disorder, can be managed with medications such as amphetamines (Adderal) to improve focus, increase concentration ability, and decrease vulnerability to distraction.

In children and adolescents, medications can sometimes be used to help diagnose mental health conditions. For example, when a child has a difficult time paying attention in class, is falling behind with school work, and is having severe tantrums involving aggression, diagnoses such as attention deficit hyperactivity disorder, post traumatic stress disorder, depression, or even bipolar disorder might be considered. A stimulant typically used to treat ADHD may be tried to see if the child responds well to the treatment and the symptoms come under control. The successful use of the medication helps to secure the ADHD diagnosis. If, however, a child is thought to be bipolar and is placed on aripiprazole (Abilify) or lithium with no effects or worsening of symptoms, the diagnosis of bipolar disorder may be ruled out and alternative diagnoses will be considered.

 

Drawbacks of Psychotropic Medications

No medication comes without risk of side effects or other interferences in the body. Some antidepressants can reduce the ability to experience emotions, even pleasurable emotions, and can eliminate interest in sex.  Behavior management medications often cause drowsiness and withdrawn behavior. Attention disorder medications can interfere with appetite or sleep and create additional problems for a child. Some psychotropic medications cause tics, nightmares, and even some of the same symptoms they aim to help, such as hearing voices. Some medications used to treat thought disorders can cause lifelong side effects that do not go away even when the medication is stopped.

Antipsychotic medications such as resperidone (Risperdal) or olanzapine (Zyprexa) as well as some of the mood stabilizing agents and antidepressants can cause weight gain to varying degrees. A few pounds can profoundly impact the developing child’s self-esteem, performance, and relationships. Some medications are linked to obesity, even when used for only a few months. Not only does weight gain impact self confidence but it also places children and teens at risk for diabetes, heart disease, eating disorders, and a lack of compliance with treatment recommendations. Rapid weight gain also decreases the motivation to exercise, the desire to socialize, and the ability to engage in typical physical activities. Weight gain with psychotropic medications is a serious issue that needs to be taken into account.


A Multimodal Approach to Managing Mental Health Disorders in Children

Managing mental health issues and the symptoms experienced by children and adolescents involves many modalities:

  • Medication treatment, or psychopharmacology, can alleviate or lessen the symptoms that accompany many mental health disorders. For example, medication may decrease the impulse to tantrum, help a child regulate physiologic responses to emotions, or eliminate auditory hallucinations. In addition, proper medication support can provide behavioral stability and support with emotional regulation that a child or teen may need to readily engage in other forms of therapy. For example, a very depressed teen who cannot control her crying when she needs to be able to talk about her abuse and history can feel more in control emotionally with the right medication, allowing her to discuss the important issues and aid in her healing.

  • Behavioral therapy, for example using reward charts, can help increase positive behaviors and decrease negative acting out.


  • Cognitive behavioral therapy can help correct a pattern of negative thoughts that interfere with the ability to relate to others.


  • Play therapy can help heal past trauma and facilitate a child’s return to normal functioning.


  • Child-parent psychotherapy involves working directly with the parent and child to address issues within their relationship and help the child increase healthy ways of interacting and functioning.
    Parents are helped to become more reflective, develop a deeper understanding of their child and their role in their child’s life. They also learn how to interact with their child in ways that promote a healthy and secure attachment and to support a healthy growth and development trajectory. Parent coaching can also be an element of this modality.


  • Dialectical behavioral therapy (DBT) can provide important skills, such as distress tolerance and emotional regulation, in struggling adolescents and help them integrate them into their daily interactions.

All of these treatments are valid and can help manage symptoms, facilitate healing, and return children to optimal functioning.

 

When a Child Should Be Placed on Psychotropic Medication

Medication can be important to successfully treat a child or teen dealing with a mental illness. Medication can be helpful when a child is disturbed or overwhelmed by his or her own behavior and has not been able to learn to manage the symptoms through other means. A medication trial might help control the interfering symptoms and increase self-esteem and functional ability.

Children who are self-abusive, impulsive, or aggressive to others may need medication to help them manage their impulses and aggression. Children and teens who hear voices or have visual hallucinations may require medication to alleviate these symptoms. Medications can also support physiologic regulation that often gets out of sync with mood disorders and trauma; in other words, medication can help stabilize sleep patterns, appetite, and concentration.

Medication use can be helpful and is often instrumental in treating mental health issues in children and teens. The concerns lie in what medications are being used, if they are being well monitored, and if they are the right ones for the child based on symptoms, age, functional ability, and improvement.

 

Recommendations for Best Practice

The American Academy of Child & Adolescent Psychiatry  makes the following recommendations for the use of psychotropic medication with children and teens:

  1. Before initiating pharmacotherapy, a psychiatric evaluation is completed. Understand the child as fully as possible. A psychiatric evaluation should include a family background, therapies already tried, current medications, the child’s ability to function in multiple places, i.e., home, school, social circles, and mental health status. This information provides a baseline for starting any kind of treatment.

  2. Before starting pharmacotherapy, a medical history is obtained, and a medical evaluation is considered when appropriate.
    A medical history is critical to understanding any health issues that could relate to the child’s symptoms. For example, a history of a head injury might relate to the development of aggressive behavior, or a seizure disorder history might relate to a decreased ability to focus. A medical evaluation would help establish baselines on such issues as growth (height and weight), cardiac function, and elimination patterns (particularly important in diagnosing encopresis and enuresis).

  3. The prescriber is advised to communicate with other professionals involved with the child to obtain collateral history and set the stage for monitoring outcome and side effects during the medication trial.
    Children act differently depending on their environments; their behaviors and emotional states can vary with different caregivers or other people. For example, a child can function well at school and thrive in a structured environment, but act out at home due to the presence of domestic violence. Gathering baseline information will help understand the impact of the medication over time.

  4. The prescriber develops a psychosocial and psychopharmacological treatment plan based on the best available evidence.
    A treatment plan is important to think through all necessary potential treatments as well as medication options. The evidence supporting these choices should be addressed as well.

  5. The prescriber develops a plan to monitor the patient, short and long term. Short-term monitoring helps to assess for any developments or increases in suicidal ideation as well as initial side effects, such as stomachaches or drowsiness. Long-term monitoring helps assess the continued impact and potential changes over time.

  6. Prescribers should be cautious when implementing a treatment plan that cannot be appropriately monitored. Treatment plans should be followed and evaluated over time. Treatment modalities or requirements that cannot be monitored should be reconsidered.

  7. Prescriber provides feedback about the diagnosis and educates the patient and family about the child’s disorder, and the treatment and monitoring plan. The patient and caregivers should be kept updated and educated about the diagnosis, what it means, the treatment of the disorder, and the monitoring of the treatment plans.

  8. Complete and document the assent of the child and the consent of the caregivers before initiating medication treatment and at important points during treatment. Assent and consent needs to be given before treatment starts. Both children and caregivers should be given easy-to-understand information and have the risks and benefits of medication explained to them.
     
  9. The assent and consent discussion focuses on the risks and benefits of the proposed and alternative treatments. The risks and benefits of medication and of alternative treatments, such as psychotherapy, should be discussed.

  10. Implement medication trials using an adequate dose and for an adequate treatment period. If medications are tried, the dosage needs to reach therapeutic levels and the medication needs to be tried for an adequate period to reach a therapeutic stage. Some medications work quickly, and leave the system quickly. Other medications need to reach certain levels to work well, and then those levels need to remain stable. For example, Zoloft is often used to treat obsessive-compulsive disorder with doses as high as 200 mg./day. With depression, the basic dose is 50 mg./day. Lithium is a medication that needs to reach a therapeutic level and be kept stable to be effective.

  11. The prescriber reassesses the patient if the child does not respond to the initial medication trial as expected. Finding the right or best medication might take time; some children do better on one medication than another, just like adults. At times, several medications might be tried before the best medication for that individual is found. For example, certain stimulant medications can have no effect on some children but work extremely well in others. The same phenomena can happen with antidepressants. The underlying reasons for specific symptoms may differ from person to person and the medications used to treat those symptoms can differ as well. 

  12. The prescriber needs a clear rationale for using medication combinations. Combining medications increases the risk to the child; understanding what is needed and what medications compliment one another is key. For example, combining an antidepressant for depression and a stimulant for ADHD might be warranted. Placing a child on two antidepressants at the same time or two antipsychotics does not make sense in most cases.

  13. Discontinuing medication in children requires a specific plan.
    Most medications should not be stopped abruptly. They should be tapered off. Discontinuing medication should be part of a plan within the overall treatment goals

 

Questions Judges and Attorneys Should Ask

Judges and attorneys should consider the following questions when considering the best interests of or advocating for a child or teen in care. Children and teens have little, if any, power over their lives when they enter care. They generally lack the knowledge to understand what they need medically, regardless of the type of treatment needed. Asking the following questions will help identify their needs and determine which recommended treatments are in their best interests.

What is this medication needed for?

What kind of symptoms is this child experiencing? Are these symptoms interfering with the child’s ability to function? Are these problems an issue in multiple environments?

Were you able to obtain an accurate medical, behavioral, and psychological history from parents and past providers?

Children in foster care do not always have a consistent caregiver who can be a reliable historian for what a child has experienced or what kinds of symptoms they are dealing with. Parents who are in conflict with their child may exaggerate symptoms or blame the child when they are really at the root of the presenting issues. Other parents may not have been around their children enough to provide accurate information. Parents and other caregivers can also become so frustrated by a child’s behaviors that they exaggerate the child’s symptoms to gain added support and sympathy. It is important to explore the source of the information about the child.

What else has been tried?

Has counseling been provided? Has it been consistent? Has the child had a psychiatric evaluation? Has the child had a medical examination?

What other modes of treatment or intervention will also be provided?

Medications should never be the sole mode of treatment for mental health disorders. Counseling should be provided to help children learn to manage or minimize their symptoms. Children often need to learn new skills, such as anger management or problem solving, to help them interact with others more successfully. Some children need to talk about their trauma or their grief to make sense of and resolve it; medication will not do this for them. Additional types of treatment may include Play Therapy, Social Skills Group, Parent-Child Interactive Therapy (PCIT), Dialectic Behavioral Therapy (DBT), Cognitive Behavioral Therapy (CBT), Child-Parent Psychotherapy, Parent Coaching, and Anger Management Groups.

Who will monitor the ongoing use of this medication? How often will this child be seen?

Successful medication management includes regular follow-ups. Especially when first started, medications often need to be adjusted for proper dosage or better timing. The development of side effects needs to be monitored. In children, medications often need to be slowly introduced over several weeks; the incremental adjustments will need to be monitored. Medication changes and ending a medication often require tapering as well. About 20% of people have some type of difficulty with the first psychotropic medication they are prescribed and will need to work with their mental health provider to find a better treatment option. It is important to consider who will take the child to appointments on a regular basis so a consistent adult is also well informed of the medications being used.

What are the possible side effects of this medication and how will they be handled?

Some medications carry transient side effects, such as stomach upset or initial drowsiness. These often disappear over the first few days on the medication or they can be minimized by taking the medication at night rather than in the morning. Other side effects, such as vomiting, confusion, or inability to sleep, may mean this medication will not work with this child or that the child needs additional medication to balance the effects. Some side effects are seen weeks or even months after a medication is introduced. Some antipsychotics lead to rapid weight gain while some stimulants used to treat attention disorders lead to significant weight loss—these issues can impact overall health and can add to self esteem and other mental well-being problems.

What evidence supports the use of this medication with children?

What do we know about how this medication works in children? Are there safety warnings that go along with this medication? What evidence do we have that it will not harm the child? Is this medication well tolerated in children?

Will this child be able to comply with the prescribed medication?

Is there someone available who can assure the child has regular access to the medication and that it is being given as directed? Is this medication easy to use? For example, is it a once-a-day dose versus a four-times-a-day dose? Is the type of medication right for this child? For example, is there a liquid form available for a child who cannot swallow pills? Will additional lab tests be needed to start or sustain use of this medication? For example, will the child need a baseline EKG to assess for cardiac functioning or will the child require regular blood tests to assess medication levels. Can the patient afford the drug? If a patient cannot afford a medication, he or she will not be able to take it. Is it covered under Medicaid? Medicaid often has rules for what kinds of medications it will cover; alternative medications can often be prescribed, but sometimes a very specific drug may be needed for certain symptoms.

Does the child agree with taking this medication?

Despite the age of consent, how does this child feel about being on this medication? Has it been discussed with the child? Has the child been told what to expect? Is someone talking regularly with the child about how it feels while on this medication?

Who has given permission to begin this child on medication?

Who should be giving permission? The parent? The foster parent? The prescriber? The child’s advocate? The child? The social worker? Do the people involved in this child’s life know of this medication and understand the risks and benefits? Have they been taught how to properly administer and monitor this medication?

What other medications is this child on? Can this medication be safely combined with the current medication?

Is the child already on medications for other things such as asthma or acid reflux? Can this new medication be safely used with the current medications? Who has assessed this? Does the prescriber of the psychotropic medication know what the child is already on? What over-the-counter medications, vitamins, or naturopathic medications is the child taking?

How will this medication help improve this child’s functioning?

What challenges is the child struggling with that should change with this medication? Will this make life easier for this child?

What are the risks versus benefits of using this medication? What are the risks versus benefits of not using the medication?

It is critical to understand the risks of any medication and of any other intervention or therapy. Equally important is understanding the benefits of using the medication or other therapies. The benefits need to outweigh the risks. Both the patient and the caregivers need to fully understand the risks and benefits as well.

Is a second opinion warranted in this case?

Cases involving children on multiple medications, young children under six, and the use of atypical medications should always be reviewed by other practitioners. Children who have been difficult to treat or who have tried various medications previously may require a second opinion.

 

Conclusion

Psychotropic medication use in children and adolescents has increased over the past decade. Many medications used today are safer, have fewer side effects, and are more effective than medications used 15 years ago. However, little research has studied the long-term effects of these medications or their effects on children and adolescents. Despite this lack of knowledge, psychotropic medications are used to treat and manage behavioral, emotional, and psychological symptoms experienced by children and teens.

Children in foster care or in other state care appear especially vulnerable to medication use. Concerns continue to be raised over adequate monitoring, second opinions, use of multiple medications at once, consent for the use of medications with children in care, and providing other necessary treatments such as counseling. Evidence shows individuals experience greater improvement when medication is combined with counseling than without.

The risks and benefits of treating a child with and without medication need to be examined with each medication considered. Children should be on the least-potent medication and the lowest possible dose, and for the shortest amount of time. Their developmental progress across all domains should be considered and protected. Psychotropic medications should be supportive and helpful and never place a child at risk of harm.
 

JoAnne Solchany, PhD, ARNP, is a Board Certified Psychiatric Nurse Practitioner and Therapist with infants, children, and families in Seattle. Her focus is on children and families in the child welfare system, child-parent relationships, and infant mental health.

 

This article was adapted from Psychotropic Medication and Children in Foster Care: Tips for Advocates and Judges, a new practice and policy brief developed by the ABA’s Improving Understanding of Maternal and Child Health Project, a project of the ABA Center on Children and the Law. 

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