The audit reviewed the cases of 168 children prescribed psychotropic medications while in protective custody and enrolled in one of two MassHealth benefit programs. In total there are nearly 4,000 children, almost a quarter of all those in DCF protective custody, who had a prescription for at least one psychotropic medication during the audit period between June 1, 2019, and Dec. 31, 2023.
Medications for anxiety and depression, antipsychotics, stimulants, and mood stabilizing drugs help children manage mood swings, anger, and delusions, the report states. But they can have serious side effects, including mania, seizures, and suicidal thoughts.
DiZoglio emphasized how vulnerable children in DCF’s protective custody can be.
“A lot of these children are left without the assistance of family members and other supports, and that’s why they end up in custody,” she said.
Daniel Mahoney, deputy chief counsel of the children and family law division at the state public defender’s office, described DCF’s handling of children’s medication as a longstanding concern in the state.
“The audit shows a lack of consistent court approval and documentation for potentially harmful medications prescribed to children in DCF custody,” he said in an emailed statement, “which undermines the legal and medical safeguards designed to protect these children.”
As far back as 2009, the Office of the Child Advocate expressed concern about the agency’s use of psychotropic drugs, according to its 2015 annual report. The agency needed to do more than just medicate children, according to the child advocate, which serves a watchdog role for DCF. Prescriptions should be a facet of a larger behavioral health plan that is routinely reviewed and evaluated, the report said.
A spokesperson for the child advocate said both his office and DCF recognize the importance of maintaining proper records.
Yet the audit determined that despite the child advocate’s earlier warnings, children who were medicated were still not receiving complementary treatment. Among the cases sampled, 25 children received no therapy at all and 34 did not receive therapy for more than four months. The group studied included 28 children who had expressed suicidal thoughts and were taking psychotropic medication.
DCF did not respond to a request for an interview Thursday but issued a statement saying it largely agreed with the audit’s findings and is addressing them. The agency has a team of experts, including a child psychiatrist, psychiatric nurse consultant, and psychiatric social worker, who offer guidance on prescribing psychotropic medications for children. The psychiatrist also oversees a monitoring program that reviews requests to prescribe antipsychotics for children.
The agency is leaning more heavily on records from MassHealth to better track prescriptions, and now conducts a medical review whenever a child is prescribed an antipsychotic, according to the statement.
Maintaining accurate and current medical records is a challenge throughout the child welfare field, said Dr. Christopher Bellonci, a psychiatrist and chief medical officer at the Judge Baker Children’s Center, which provides services and training related to children’s behavioral health. Digital data systems can be unwieldy, foster parents and case workers may not exchange full information about medical care, and accurate record keeping is often time consuming.
“There are lots of places where this can break down,” Bellonci said. “That’s not an excuse by any means, but it is a reality.”
There were 36 children in the sample who had received antipsychotic medication, but four were medicated without court permission, the audit found. That’s a violation of state regulations that require the agency to obtain court permission, called a Rogers Order, before administering antipsychotic medications to children too young to give legal consent. Six children received antipsychotics after a court order had expired. In one case, the child was still taking medications eight months after the court order expired.
In the majority of cases, DCF didn’t maintain accurate records of consent or court approval for psychotropic medications, according to the audit.
DCF offered several explanations for its the failure to obtain required court approval. In one case, the agency told the auditors, the child was not in protective custody and had been prescribed medication before interacting with DCF. In another case, the prescription was filled but never taken. In another case, the COVID-19 pandemic caused delays in the court hearing.
The audit noted DCF records contradicted or couldn’t confirm the agency’s explanations. It also stated that even if a child didn’t take medication, a prescription should not have been filled without a judge’s order.
Moreover, the auditor found that DCF doesn’t require monitoring of the Rogers process to ensure it’s followed properly.
The agency replied in the auditor report that it would do a better job tracking court actions.
The audit revealed all but two of the 168 children prescribed psychotropic medications had gaps in their digital medical records. Those records are critical to children’s care, DiZoglio said, and if a child needs emergency care a doctor would rely on them to determine a safe course of treatment. Among the reviewed cases from the two MassHealth plans, almost 88 percent either had no information about children’s prescriptions related to mental or behavioral health treatment, or incomplete information.
Record keeping for doctor appointments and mental health services were equally spotty.
“DCF could be creating a treatment plan that is not safe or effective for a child, because there is important information missing that would affect this child’s health care,” the auditor report stated.
The department also doesn’t have procedures to give additional attention to children taking prescribed doses that exceed Food and Drug Administration recommendations.
Jason Laughlin can be reached at [email protected]. Follow him @jasmlaughlin.
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