September 1, 2011: Led by Laurel K. Leslie, MD, MPH, Director of the Center for Aligning Researchers and Communities for Health (ARCH) at Tufts CTSI, Thomas Mackie, MPH, MA, Tufts Medical Center and Brandeis University, and Justeen Hyde, PhD, the Institute for Community Health and Harvard Medical School today released an examination of the informed consent system for administering antipsychotic medications to youth in custody of the Massachusetts Department of Children and Families (DCF). The study was commissioned by the Office of the Child Advocate of the Commonwealth of Massachusetts and funded by the Massachusetts Court Improvement Program. Throughout this research, Dr. Leslie and colleagues received ongoing input and feedback from a working group composed of State policymakers, lead agency administrators, researchers, and expert content consultants.
Over the past decade, psychotropic medication use in youth in the general population has increased 2-3 fold and the use of more than one psychotropic medication at the same time has increased 2.5-8 fold. However, estimated rates of psychotropic medication use for youth in child welfare custody are much higher (ranging from 13-52%) than those for the general youth population (4%). There is therefore rising concern about the appropriate use (both over- and under-use) of psychotropic medications for youth in child welfare custody.
In response to these concerns, George W. Bush enacted a federal mandate, Fostering Connections to Success and Increasing Adoptions Act, Public Law 110-351, (P.L. 110-351) in 2008, which calls for state child welfare systems to partner with other youth-serving organizations to develop plans for the oversight of health and mental health services, including psychotropic medication use. Many states, including Massachusetts, are examining components of their oversight plans, including the process by which informed consent is conducted for youth in child welfare custody (see Multi-state study on psychotropic medication oversight in foster care).
The Massachusetts DCF was one of the first state child welfare departments nationally to house the informed consent process for antipsychotics, a specific class of psychotropic medications, in an agency external to the child welfare department. Since 1987, DCF has required use of the judicial system to authorize of the prescribing of antipsychotic medications (e.g. olanzapine, aripirazole) for youth in DCF custody through a mechanism called the Rogers process.*
The study involved 1) interviews with key informants involved in the Rogers process across the Commonwealth, and key informants from four other state child welfare agencies (California, Connecticut, Illinois, and Texas), as well as 2) review of existing policies and guidelines, for Massachusetts and the four other states selected, available on public websites or provided by staff. Key informants were drawn from DCF, the courts and legal systems, other child-serving state agencies, health and mental health care providers, and consumers.
The study participants, in aggregate, were divided almost equally with regard to whether they recommend the system be minimally, moderately, or substantively changed. Notably, recommended levels of change to the current Rogers process varied considerably by stakeholder group. For example, legal stakeholders were almost three times more likely to recommend minimal changes than were health care providers. Child welfare professionals were divided almost equally among the three levels of recommended change. Just under half of consumers recommended substantial change to the current Rogers. The study also provides a number of recommendations provided by study participants as well a summary of innovations occurring in youth-serving organizations located within the Commonwealth (including the Probate and Family Court) and in child welfare agencies located in the four other states examined.The findings of this research may assist Massachusetts in its deliberations regarding the Rogers process, as well as inform the efforts of other state child welfare agencies and relevant stakeholders as they respond to P.L. 110-351.
The Study Report is available here. An abbreviated Executive Summary is here. An appendix, including detailed summary of study findings and summaries of the four other state systems for informed consent, is available here. The Study Report was funded by the William T. Grant Foundation and Tufts CTSI.
*In this report, “youth in DCF custody” excludes youth placed in custody through a voluntary agreement or through Child In Need of Services (CHINS) proceedings. Youth in DCF custody may be in a variety of placements ranging from placement with kin or non-relative foster parents to placement in residential care or an inpatient setting.