Reposted from CHD: The Defender

A federally funded school-based health center (SBHC) in Maine reportedly gave prescription anti-depressant pills in a plastic baggy to a 17-year-old girl without her parents’ knowledge or consent, her father told The Maine Wire.

When the girl’s father, Eric Sack, found the pills — which his daughter told him were Zoloft — he complained to the school.

Zoloft carries a black box warning — which warns of possible serious adverse reactions — indicating the drug can cause suicidal ideation, particularly in people under age 24, when they first start taking the drug.

Sack kept his daughter home from school the following week to make appointments with a doctor and therapist — a decision that resulted in someone at the school or the health center reportedly contacting Child Protective Services, which investigated the family.

The recent push by the U.S. federal government to rapidly expand the number of SBHCs across the country to improve healthcare for children by offering “primary care, mental health care, and other health services in schools” — particularly in underserved communities — is raising red flags.

Critics say they’re concerned children might receive, or be pressured into receiving, unnecessary or unwanted medical interventions without their parents’ knowledge or consent.

Georgia attorney Nicole Johnson, co-director of Georgia Coalition for Vaccine Choice and a consultant to the Children’s Health Defense (CHD) legal team, told The Defender:

“This case in Maine really is everything we worried about. It is almost the worst-case scenario. A young person is getting a drug with a black box warning. They come home with it. It doesn’t even have any warning label on it. The parents haven’t been told, and the drug is in some plastic bag that anybody — any other child in the house, or their peers — could have access to. It could be a very dangerous situation.”

Maine goes all in on SBHCs

The Bulldog Health Center at Lawrence High School in Fairfield, Maine, which reportedly gave the Zoloft to Sack’s daughter, offers primary care services onsite to middle and high school students.

It is operated by Maine’s HealthReach Community Health Centers, a nonprofit funded largely by patient fees and grants. HealthReach reported it also received $4.8 million from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS), although further grant details are not available.

HRSA also awarded approximately $25 million in 2022 to expand 125 SBHCs, including $81,728 to HealthReach. HRSA also awarded $5 million to 27 centers in 2021.

Those grants came in addition to $50 million in HHS grants authorized by the Biden administration and Congress in 2022 to states “for the purpose of implementing, enhancing, or expanding the provision” of healthcare assistance through SBHCs using Medicaid or the Children’s Health Insurance Program, The Defender reported.

In Maine, the Department of Education and Department of Health and Human Services (DHHS) announced in marzo 2022 plans to expand SBHCs across the state through the use of one-time federal American Rescue Plan funding for $2.4 million.

Funds are being distributed in two-year grants during 2021-24 to establish 12-15 new centers in Maine.

In 2022, there were at least 22 SBHCs in the state.

State funding covers startup costs plus costs for uninsured and underinsured students, for additional time needed during visits and for “confidential care that may not be billed to insurance,” according to a presentation by DHHS.

In the SBHC partnership, the school district acts as the “host,” coordinating enrollment in the SBHC program, parental consent and services. The healthcare provider is the “sponsor,” which receives the funding and provides the services.

A key justification for the expansion of the centers, in Maine and nationally, is an “increased need for mental health care.” The demand for mental health services for children and youth were at “an all-time high,” according to DHHS’ presentation, and the COVID-19 pandemic made disparities in access to healthcare more severe.

In the 2020-21 school year, 77% of the reported SBHC visits were for mental health services. DHHS also indicated that increased emergency department use by youth was driven by suicidal ideation among adolescent females.

‘I’m looking out for the best interests of my daughter’

The Maine Wire reported that when Sack found a zip-close bag containing small blue pills in his family home, his daughter told him she had been prescribed the pills by the Bulldog SBHC.

He said he was concerned the prescription given to his daughter violated his parental rights, but also that the center sent unlabeled drugs with no child-resistant container home with his daughter to a household where two younger children also lived.

Sack said he contacted Lawrence High School Principal Dan Bowers, who told him the clinic was a separate entity that he had no control over.

Sack also said a representative from the Bulldog Health Center told him they could legally prescribe the medication to his daughter without informing him. They did not comment on the lack of a label or safety container, he said.

Concerned, Sack pulled his daughter out of school the following week.

“I’m looking out for the best interests of my daughter. That’s why I pulled her out of school,” Sack told The Maine Wire. “Because I don’t think she really ought to be there if they’re going to start giving her pills, you know? Until I sit down with a doctor that I pick for my daughter, not through the school.”

The Maine Wire reported what happened next:

“On Thursday, an agent from Child Protective Services (CPS) called Sack and informed him that he would be arriving shortly to make a surprise visit to his home to conduct a child welfare investigation.

“‘They called and said it was an emergency situation at my house, that I was pretty near holding my daughter hostage, is what the gentleman that came yesterday told me,’ Sack said.

“‘He had information that only the school and Bulldog Health Center had,’ he said.”

Members of the family were questioned individually and as a group by CPS Agent Dylan Wood, who eventually indicated the complaint against him was unfounded, Sack said.

The Defender reached out to Sack, who said he is seeking legal counsel and declined to be interviewed at this time. The Bulldog Health Center and Bower did not respond to a request for comment.
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SBHC consent forms may be confusing for parents

Sack told The Maine Wire that he or his wife may have signed a consent form at the start of the school year, but he still thought the incident violated his rights.

Justine Tanguay, an attorney with nearly 20 years of experience advocating for children in various areas of the law, told The Defender these consent forms are a key issue for parents to be aware of.

At the start of each school year, parents are given many forms to sign and they likely don’t realize they are signing away their rights over their children’s healthcare, she said.

Most parents, she said, tend to assume that school medical consent forms allow a school nurse to administer first aid, treatment for minor illnesses or emergency treatment.

“But that is not what this is,” Tanguay said. “It’s something much more nefarious.”

Unlike school nurses, SBHCs function as primary care clinics. By signing consent forms, parents may unknowingly give those who run the SBHC the legal authorization to provide “comprehensive healthcare.”

This could include — but may not be limited to — “the ability to provide preventative treatment, behavioral and mental health services, reproductive counseling, lab and prescription services, various medical screenings, immunizations and disease management,” Tanguay said.

She said parents should know:

“One form they may receive at the start of the school year is a blanket consent form, and if they sign it, they are basically abdicating their parental rights to make medical decisions for their kids.

“The school won’t need to reach out and ask, ‘Hey, can we test your child for whatever thing?’ No, they’ve signed the form, they’ve already said, ‘Do whatever you want.’”

But, she said, parents who signed such a form have the right to revoke it.

Tanguay added that consent forms can be difficult to understand and the forms are not all the same.

She suggested parents whose children go to schools with SBHCs should find out what the forms they are signing say and decide what they want to opt out of.

Tanguay also said Bower’s alleged statement that the clinic is not under his control is true. These clinics are inside of the school, but are separate entities not administered by the school, she said.

Yet, the school is responsible for obtaining signed consent forms from the parents, which generates confusion.

That means parents are not giving informed consent, Tanguay said.

“Did the father in this case know what he was signing? Was there a warning on the document that stated ‘You are abdicating your parental rights to make medical decisions’? So did he understand the implications of the form? I doubt it,” she said.

Teen mental health crisis spurred federal funding for SBHCs

At least since the start of the COVID-19 pandemic, public health officials and organizations have been sounding the alarm about a mental health crisis among children.

The American Association of Pediatrics (AAP) declared the children’s mental health crisis a national emergency in octubre 2021 and the surgeon general in May of this year issued a public advisory warning that social media can pose a “profound risk of harm to the mental health and well-being of children and adolescents.”

In fact, suicide rates, particularly among teenage girls, have been on the rise since 2008.

Those public announcements pointed to the COVID-19 pandemic, racism, and social media as the causes of higher rates of mental illness among teens.

But other experts, including Vinay Prasad, M.D., MPH, have cautioned against those assumed links, instead pointing to policies such as lockdowns and school closures that isolated kids and teens and forced them online for large periods of time, compromising their education and their social lives.

Groups like the AAP, a strong supporter of SBHCs, have used the mental health crisis to call on the Biden administration to fund expanded access to screening, diagnosing and treatment for children, arguing access to “school-based mental health care” should be a priority.

The administration responded with new policy measures, including the Bipartisan Safer Communities Act — which made $11 billion available for mental health services — and the American Rescue Plan Act. Both offer funding explicitly for school-based mental health services for students, KFF Health News reported.

Many of these resources have funded the expansion of SBHCs.

Professional associations including the AAP and the American Academy of Family Physicians recommend antidepressants, often combined with therapy, to treat moderate-to-severe mental health issues in young people.

But the use of antidepressants for young people — one tool for addressing mental health issues by the healthcare industry — has been controversial, with many advocates arguing for decades that the “heavily-marketed mind-altering agents” are prescribed too frequently to children and the drugs’ effects are understudied.

A 2016 review of over 70 trials published in The BMJ found an increase in self-harm and aggression in children and adolescents taking antidepressants, but not in adults.

Because of these concerns, the U.S. Food and Drug Administration (FDA) put a black box warning on many antidepressants in 2004, warning that they increase the risk of suicidality (defined as serious thoughts about taking one’s own life or planning or attempting suicide) among children, adolescents and young adults.

Despite those concerns, there has been a steady increase in the last decade in the number of antidepressants prescribed to children.

Many medical researchers have called on the FDA to eliminate these warnings, alleging they led to a reduction in the number of young people who take antidepressants. Others have found these claims are based on “weak evidence.”

Advocates for children’s mental health, such as Tom Madders, director of campaigns at the U.K.-based YoungMinds, a children and young person’s mental health nonprofit, said antidepressants could play a role in some young people’s mental health, but that it is “crucial” they be coupled with other therapies and that they are not used as a substitute for other treatments.

Even those who strongly advocate for the use of antidepressants for children caution about side effects and the importance of parental education and informed consent.

A 2019 article in Current Psychiatry underscored that:

“It is important that clinicians and families be educated about possible adverse effects and their time course in order to anticipate difficulties, ensure adequate informed consent, and monitor appropriately.

“The black-box warning regarding treatment-emergent suicidal thoughts or behaviors must be discussed.”