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Raising Red Flags: A Look at State Policies for Prescribing Psychotropic Meds for Foster Children

As part of NCYL’s PsychDrugs Action Campaign, we have asked current and former foster youth to talk about their experience with psychotropic medications while they were in foster care. Here are some of their stories:

John’s Story

By Whitney Richey Rubenstein

7a1057107eJohn1 a former foster youth, said physicians continually told him he was “just a troubled young person” and continually prescribed him dangerous cocktails of psychotropic medications. He said no one ever asked him how the medications made him feel, if he was having side effects or if he was benefiting from the drugs. John never shared how he felt because he “didn’t know what to say to anyone.”

Had anyone bothered to ask him, and had he felt he would be “really listened to,” John said he would have gladly told them.

The medications “made me feel like a zombie. Like I was asleep and not really knowing what I was doing most of the time,” he said, adding that he was “gaining weight like it was nobody’s business.” By the tender age of 14, John was a size 44, weighing in at well over 200 pounds. No doctor ever told him that weight gain was a side effect of the medications.

“I never thought medications would make me look like a panda bear,” John said.

Reflecting on his life before medication, John remembers being alert and active.

“After I started taking the medication, I was less alert and less myself. Every time I took my meds I was losing part of me,” he said.

John is now 19 and living on his own. From the ages of 13 to 18, he was in foster care, moving in and out of four or five different placements, mostly group homes. During those years, he remembers having cycled through three different caseworkers, four prescribing physicians, and four therapists. Every time he changed placements, he started over with new doctors who would prescribe new medications, and with new therapists who had him retell much of his story even though, in John’s words, “the therapist(s) wasn’t even helping.”

John’s remembers that the first time he took medication was when he entered foster care at 13. For the next five years he remained medicated. He said he was prescribed anywhere from two to 10 medications at one time. At one placement he recalls staff telling him “you take more meds than most of the kids here.”

The medications he was prescribed included Abilify i, Trileptal ii, and Seroquel iii. Two of these medications have not been approved by the FDA for use in adolescents and the other carries with it extreme side effects including suicidality.

Need for State Policy: Many Foster Children Prescribed Psychotropic Drugs

John’s story is not unique. High numbers of foster children are being prescribed psychotropic medications. In Texas, data shows that 32.2 percent of all children in foster care and 58.2 percent of teens in care are receiving psychotropic medication.iv To put this in perspective, only 7.1 percent of non-foster children in the state are medicated.v Similarly, in California, 56.3 percent of foster children living in group homes are on one or more psychotropic medications.vi These medications are often used as a quick fix or a way to control behavior. Having a child “sleep through” their time in foster care is simply easier than identifying proper services and alternatives that would actually help them.

Despite the large number of children in foster care receiving psychotropic medication, a recent study conducted by Tufts University reported that child welfare agencies in only 26 states have some form of written policy or guidelines on psychotropic medication.vii It is important to note that the Tufts study looked only at child welfare agency policy, and psychotropic medication policies, if they exist at all, may also be found in state regulations and Medicaid manuals.

Among states that have adopted policies, there are considerable differences from one policy to another. When viewing a snapshot of four of these 26 states – California, Texas, Nevada, and Illinois, it becomes clear that there is a lack of uniformity in approach to the issue and there remains a long road ahead to ensure that best practices are being adopted nation-wide.


It is common for foster children to be prescribed drugs designed to treat psychiatric disorders. Some of these classes of drugs include anti-anxiety, anti-depressants, mood stabilizers, and anti-psychotics.1 Antipsychotics are prescribed to many children and adolescents in foster care, but are intended to treat schizophrenia, a disorder generally not diagnosed until adulthood.

1 GAO, Foster Children: HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions, GAO-12-201 (Washington, D.C.) Dec. 2011, at 6.


Key Components of Existing State Policies

The American Academy of Children and Adolescent Psychiatry (AACAP) has established guidelines for the administration of psychotropic medications to foster children. The guidelines recommend that states create policies that address “non-standard or unusual” medication regimens, the process of consent, and the monitoring and oversight of foster children prescribed psychotropic medications.viii In a recent report on psychotropic medication and foster youth, the federal General Accounting Office (GAO)relied on these guidelines to determine where individual states stand on policy initiatives. Further, while states are not mandated to follow these guidelines, many states have implemented policies that reflect them.

Red Flags

Many states that have created a psychotropic medication policy for foster children have identified red flags, or circumstances that signal the need for heightened scrutiny.

In Texas, there are eight criteria that indicate need for further review. The criteria, developed by a panel of policy makers, professors, and medical experts, include circumstances where a child is prescribed five or more psychotropic medications at the same time or when “psychotropic medications are prescribed for children of a very young age. . . .”ix

In Nevada, there are only four red flags. These include when a child is prescribed medication under the age of 4 as well as when a child is prescribed three or more psychotropic medications. Nevada additionally includes a red flag for when psychotropic medication is used in a manner that “has not been approved or tested by the United States Food and Drug Administration including the use of medication for a child of an age that has not been tested or approved or for a condition for which the use has not been tested or approved.”x These criteria were born out of legislative advocacy on the tracking and monitoring of foster children on psychotropic medications.

Illinois, like Texas, sets forth eight criteria developed by the child welfare agency’s psychiatric consultants at the University of Illinois, Chicago. Heightened reviews will occur in instances where a child has been prescribed more than four psychotropic medications at a time, has been taking the same medication for more than two years with no change in dosages, or has been prescribed more than one psychotropic medication from the same class.xi

In California, while there are no specific red flags, all psychotropic medication prescriptions require approval by a juvenile court judge.

Interestingly, none of the red flags adopted by the states prohibit use of psychotropic medication, and the presence of one or more red flags is not an absolute bar to prescribing medication. Instead, those red flags merely require additional review prior to prescribing the medication(s). While some safeguards are arguably better than none, these red flags leave the majority of the population, including foster youth like John, without any sort of protection.

What happens to the 5-year-old who is prescribed three medications of different classes? Or the teenager who is prescribed four? Is anyone tracking or reviewing their medications? If John’s story is any indication, the answer appears to be “no.”

Consent

Another area commonly addressed in psychotropic medication policy is the process of consent. In Texas, a court designates a person to serve as consenter. Possible consenters include biological parents, foster parents, or someone at the Department of Family and Protective Services.xii In Nevada, much like in Texas, the court appoints a “person legally responsible.” Unlike Texas, however, the person legally responsible in Nevada must be the biological parent or legal guardian “to the extent that they are willing and able to assume the role.”xiii Where a parent is unable to assume such a role, other possible consenters include a foster parent, attorney for the child, guardian ad litem, or caseworker.xiv

Illinois and California have different processes. In Illinois, only employees of the Department of Children and Family Services Medical Consent Unit acting as “authorized agents” can consent.xv Parents and foster parents are excluded from the consent process. Consent for psychotropic medication for foster children in California may only be provided by a juvenile court upon a medication request by a physician.xvi In some instances, the court may appoint the parent to serve in this role.

The variance in state policy leads to the question of whether one of these consenters is in a better position than another to serve the best interest of the child’s medical needs. Do conflicts arise when a caseworker or foster parent assumes this role as opposed to the child’s parent, or someone who is not directly responsible for the care and supervision of the child? Does one of these potential consenters provide more consistency for a child than another? States clearly differ on their answers to these questions.

Monitoring

Once a child is prescribed medication, best practice includes “effective medication management . . . careful identification of target symptoms at baseline, monitoring response to treatment, and screening for adverse effects.”xvii Unfortunately, most state policies fail to adequately address the monitoring process.

Texas policy provides that when a foster child is prescribed medication, “ongoing monitoring” must occur in order to track height, weight, and blood pressure, as well as any side effects and overall progress.xviii This policy, however, does not provide specific parameters for the monitoring, leaving it up to the prescribing physician(s).xix

In Illinois, the law acknowledges the importance of monitoring children on psychotropic medication by setting forth a policy that requires the prescribing physician to monitor a child’s progress every 90 days and annually assess the continued need for medication.xx

California’s only monitoring policy is the requirement that the courts monitor the child’s progress every 180 days.xxi

Nevada mandates that there be a system in place to “track and monitor” each foster child taking medication in order to ensure their physical and mental well being. The agency is not required to physically assess the child, but rather must only review records and documents to ensure they are in compliance with state law.xxii

Where a child’s medication regimen goes unmonitored, it can have detrimental effects. John recalls seeing his prescribing physician maybe once a month. However, during these appointments, he does not remember ever being asked about side effects or about how the medications were making him feel. Had he been asked, he is convinced no one would have listened. John may be right. Including youth in the treatment process has been touted as a best practice.xxiii Despite this, Illinois is one of the only states to require that a youth be provided with information about the psychotropic medication prescribed, and to provide a process for formally documenting the child’s objections.xxiv

John Today

Three months ago, John stopped taking his medication. Since that time he reports, “I feel good and am not always falling asleep. I am more alert and active.” He has lost more than 20 pounds.

“I’m glad I’m 18 because now I can tell them “no.” I felt like I had to take medication until I was 18 because I couldn’t say that I didn’t want to . . . even if I did, the people I was staying with wouldn’t care or tell the doctor. I would just be prescribed more meds.”

Today, John has more confidence. He has more plans for the future. He is working on finishing school and hopes to one day become a foster care caseworker in order to advocate for other foster youth. He has already begun serving as an advocate by creating a blog that provides a safe space for youth to share their experiences in foster care.

If John could give just one piece of advice to caseworkers, judges, and policy makers, this is it:

“If a foster child goes to see a doctor that prescribes meds, the doctor should sit down and listen to the kid he is about to prescribe to. If, after evaluation, medication seems like the right thing, they should sit down and talk about the medication and the side effects, including long-term side effects.” And, the doctor should say that if the medication is having an ill effect, the child should let him know and “see if there is anything we can do to fix it.”

John never felt heard by his physicians and says he “ended up paying a price for it in the end.” He does not want other children to suffer or to be similarly silenced by the system. Development and implementation of thorough and consistent policies by all states would be an important step in this direction.


Whitney Richey Rubenstein was a 2012 summer law clerk at NCYL, working with Senior Attorney Bill Grimm on child welfare issues.  She is in her second year at Berkeley Law.


Tiffany: A Story of Resilience

Young Woman Escapes Chaotic Childhood of Abuse, Foster Care, and Psychotropic Drugs

By Anna Johnson

Tiffany is a former foster youth who just graduated from Stanford University and has been accepted to law school in Washington. Born in New Jersey, she was placed in foster care when she was 13, shuffled from a foster home, to a grandparent, to her father’s house, and back to two more foster homes, before running away at 16. Despite the chaos of repeated moves, unsafe placements, and a steady cocktail of powerful, and harmful, psychotropic medication, Tiffany’s story is one of resilience and triumph.

A Chaotic Life in Foster Care

During her time in foster care, Tiffany was moved five times in three years. In her first foster home, she shared an attic room with other teenagers who stole her belongings. Children in the neighborhood ridiculed her for being a foster child. She and her foster siblings felt unwanted by their foster parents, who the children believed took them in for the money needed to pay the husband’s medical bills.

“We weren’t allowed to join after-school activities,” Tiffany said. “The first month I didn’t even go to school. No one had transferred my paperwork. I only had one set of clothes. They (the foster parents) took me to a thrift store after a month.”

Due to paperwork delays, Tiffany missed weeks of school and was cut off from what had been the one stable environment in her life.

“Socially, I wish I could have had a better outlet,” she said. “I wasn’t allowed (by my foster parents) to use the phone or go on a computer or do after-school programs. School was a big part of my life. I needed the stability that school and schoolwork provided.”

Caseworkers next sent Tiffany to live with her grandmother, who was legally blind, had no health insurance, and lacked the resources to care for a young girl. Her grandmother ordered her to stop taking her medications immediately, unaware of the dangers connected with abruptly stopping these powerful drugs. No one was there to monitor Tiffany’s withdrawal.

After three months with her grandmother, Tiffany was sent to live with her father. But after a few short months she was moved again after her father hit her during a drunken rage, shattering her cheekbone.

Next, Tiffany moved in with foster parents who had two biological daughters. She lived in the basement where she was forced to put all her things in the closet and under the bed so the daughters and their friends could use the space as a playroom. She said she eventually had to leave that placement because she and one of the daughters didn’t get along.

After so many changes, Tiffany was profoundly discouraged.

“When I was transferred again, I tried to commit suicide,” she said. “I was put on more medications by a psychiatrist who saw me for only 15 minutes. Even my new foster mom said the psychiatrist didn’t know enough about me.”

Next, caseworkers placed the teenaged Tiffany with a foster mother who normally took only babies.

“It was really safe, but I didn’t trust anyone anymore, and she only worked with infants. I felt like no one was listening to me,” Tiffany said. “Every home situation was a bad one, no one was willing to help me with therapy. Therapists kept changing and no one was helping me with a mental health plan. They just wanted to put me on medication.”

Tiffany felt that she was a burden being passed from one uninterested person to another.

“I needed stable therapy and someone to listen. I needed better-trained caseworkers who knew how to work with teenagers. I wish someone would have taught me how to cook and what to eat. I never learned how to do that.”

Surviving Psychotropic Medications

During most her time in foster care, Tiffany was prescribed combinations of powerful psychotropic medications. Most of the drugs were not FDA-approved for children, and even today the effects of these drugs on the developing brain are not understood.

Tiffany’s exposure to psychotropic drugs began even before she entered foster care. At age 10, Tiffany’s abusive mother found a doctor to put her on medication.

“I was taking Zoloft and another pink pill; I don’t remember what it was,” Tiffany said.

A month later, she attempted suicide (suicidality is a side effect of Zoloft). She remembers being hospitalized and having her stomach pumped. She begged the hospital staff not to return her home but her pleas were ignored. Her medications were doubled. Tiffany’s mother tied her up and locked her in a room. She escaped, called her teacher, and entered foster care. She was 13.

“The police came and I spent the night in the police office. I entered my first foster care placement an hour and a half away from home. … I only had the clothes I was wearing when the police picked me up. I gained a lot of weight from the antidepressants and was getting made fun of at school.”

“I was really sad, and didn’t know how to deal with it,” Tiffany said. She was diagnosed with borderline personality disorder and chronic depression, and was told it would last forever.

“It was really frustrating that no one was talking to me about what I needed or involving me in my case plan. I thought I would always be suicidal. The doctors said I would always be this way and always have to take medications, as if I was powerless to change that.”

Once in foster care, with rotating doctors, multiple foster placements, and changing schools, Tiffany had no say in her medical treatment, but all the responsibility for taking her medications.

“The doctors had too many child welfare cases, so they just put me on high doses of medications. I gained 80 pounds! Sometimes I was on … medications … for depression, anxiety … Zoloft, Prozac, Celexa, something for PTSD and panic attacks, something to make my blood pressure go down. There were a couple other meds but I just don’t remember. I wish I could obtain my medical history, but the caseworker hasn’t responded,” Tiffany said.

She didn’t know that Zoloft, Prozac, and Celexa all carry “black box” labels warning of suicidality. Black box labels are the most serious of the FDA’s compulsory warnings. They indicate serious and life-threatening risks. Other undesired effects of the drugs include acne, weight gain, diarrhea, and bleeding. When Tiffany began to experience these symptoms, Tiffany’s doctors prescribed additional medications. These gastrointestinal symptoms are similar to those of Crohn’s disease and ulcerative colitis.

“At one point I was on nine medications. It’s so weird when you are that young. I felt like an old person. I had bad acne, asthma, Crohn’s disease, and ulcerative colitis. It was overwhelming and hard to keep track of when to take all the medications. If I didn’t take medications the same time every day it messed with my body. No one helped me or watched me take them. I had to be responsible for taking the medications, but I never got to choose to be a part of it” she said.

Tiffany was on an ever-changing assortment of medications, but had no consistent therapist. She saw at least 10 different physicians, many of them only once.

“There was no follow-up or closure from the people that I did see more than once; when I moved placements I never heard from them again,” Tiffany said.

Tiffany Takes Control of Her Life

After three foster care placements and short stints living with her disabled grandmother and abusive father, Tiffany decided to live on her own. Often homeless, and occasionally crashing with friends when she could, Tiffany managed to finish high school and earned a full scholarship to Stanford University. Tiffany said she was lucky to have a high school guidance counselor who allowed her to have a flexible schedule so she could work and finish high school. The counselor accompanied Tiffany to California when she began at Stanford.

“I applied for QuestBridge, a low-income, high-achieving scholars program and put my name on schools as far away as I could. I didn’t know anyone at all in California. My QuestBridge scholarship covered college tuition, medications, hospital visits, and a place to stay. I also had a living stipend for one thousand dollars a month,” Tiffany said.

Tiffany had a difficult time adjusting to life at Stanford.

“I actually ended up being hospitalized twice in college [because I had] … suicidal thoughts. But I took control of my mental health. Now I am on just one small dose of medication and I am doing weekly therapy. I feel like I am in control of my treatment, my providers, and what I am comfortable with.”

Tiffany has since graduated from Stanford, has a job, and will start law school in the fall of 2013.

Dozens of people were responsible for Tiffany during her time in foster care. Each of them had an opportunity to play an influential part in her life, but from Tiffany’s perspective, few of them did. Tiffany succeeded in spite of the system, not because of it. She attributes her success to school counselors willing to go above and beyond their job descriptions to help her succeed in high school and to friends who let her stay with her when she ran away. Most of the success can only be attributed to Tiffany for knowing there was more for her than what her family, doctors, therapists, and caseworkers ever told was possible.

After a childhood of abuse, four psychiatric hospitalizations, seven years of multiple psychotropic medications, and an ever-lengthening list of one-session therapists never to be seen again, Tiffany has become a rare example of extraordinary resilience and success.

 Not her real name. Her name was changed to protect her privacy.


Anna Johnson is pursuing her master’s degree at the Goldman School of Public Policy at UC Berkeley. She is a policy intern at NCYL, working on the Center’s Psychmeds Project.


  1. Abilify is FDA approved for use in adolescents to treat bipolar mania and schizophrenia, two diagnoses which generally should be reserved for adults, but carries with it serious side effects such as suicidality when prescribed for adolescents with major depressant disorder. See FDA Abilify Information Label (Feb. 22, 2012), http://www.accessdata.fda.gov/drugsatfda…
  2. Trileptal is approved by the FDA for the treatment of partial seizures in children ages 4 to 16 years old. It has not been approved to treat psychiatric disorders, however, it is commonly prescribed for patients who have been diagnosed with bipolar disorder despite this lack of approval. See FDA Trileptal Label Information (Mar. 3, 2011),   http://www.accessdata.fda.gov/drugsatfda…
  3. Seroquel, approved for use in adults, has not been proved safe or effective for bipolar or schizophrenia in youth 18 and younger. Like Abilify, it too can increase “risk of suicidal thinking and behavior in children, adolescents and young adults taking antidepressants for major depressive disorder and other psychiatric disorders.”  See FDA Seroquel Label Information (Jul. 8, 2011),  http://www.accessdata.fda.gov/drugsatfda…
  4. Id. at Appendix XVII.
  5. Id.
  6. Cal. Dep’t of Soc. Servs. & UC Berkeley, Child Welfare Dynamic Report System: Children Authorized for Psychotropic Medications (Jan. – Mar. 2012).
  7. Laurel K. Leslie et al., Multi-State Study on Psychotropic Medication Oversight in Foster Care, (Tufts Clinical and Translational Science Institute, Boston, Mass), Sep. 2010, at 5.
  8. Am. Acad. of Child & Adolescent Psychiatry, Position Statement on Oversight of Psychotropic Medication Use for Children in State Custody: A Best Practice Guideline (2005),
  9. www.aacap.org/galleries/PracticeInformation/FosterCare_BestPrinciples_FINAL.pdf.
  10. See Tex. Dep’t of Fam. & Protective Servs., Psychotropic Medication Utilization Parameters for Foster Children, (Dec. 2010), at 8.
  11. Nev. Rev. Stat. § 432B. 197.
  12. Ill. Admin. Code tit. 89, § 325.30(o)(1) (2012).
  13. Tex. Fam. Code § 266.004(b) (2007).
  14. Nev. Rev. Stat. § 432 B. 4685.
  15. Nev. Rev. Stat. §§ 432 B. 4684(3), 432 B. 4685.
  16. Ill. Admin. Code tit. 89, § 325.30 (2012).
  17. Cal. Welf. & Inst. Code § 369.5(a).
  18. Am. Acad. of Child & Adolescent Psychiatry, Position Statement on Oversight of Psychotropic Medication Use for Children in State Custody: A Best Practice Guideline (2005),
  19. www.aacap.org/galleries/PracticeInformation/FosterCare_BestPrinciples_FINAL.pdf.
  20. Psychotropic Medication Utilization Parameters for Foster Children
  21. Id.
  22. Ill. Admin. Code tit. 89, § 325.30(g) (2012).
  23. Cal. Rules of Court § 5.640 (2012).
  24. Nev. Dept. of Children & Fam. Servs., State Child Welfare Policies and Procedures: Psychiatric Care & Procedures §§ 0209.5.6 (G),(D).
  25. Am. Acad. of Child & Adolescent Psychiatry, Policy Statement: Including Family and Youth Participation in Clinical-Decision Making (2009).
  26. Ill. Admin. Code tit. 89, § 325.40(b) (2012).
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