PARENT OR JUDGE MUST APPROVE PSYCHOTROPICS
Powerful - and potentially dangerous - psychotropic drugs will no longer be part of the "routine" medical treatment of the state's foster children.
State officials announced yesterday that a foster child cannot be given prescription stimulants, sedatives or anti-depressants without the permission of a biological parent or a judge.
"Given the risk and uncertainty with psychotropic medications, we're going to make them non-routine," said Rosie Oreskovich, who heads the Children's Administration of the state Department of Social and Health Services.
The new rules, which will be reviewed and could be changed before becoming final July 1, tighten the monitoring of behavioral medicines in the wake of the death of 6-year-old Domico Presnell last year in his Seattle foster home.
Domico's biological mother, a recovering drug addict who had been preparing to regain custody, did not know her son was taking the anti-depressants that caused his death.
DSHS officials said after Domico's death that it was inappropriate for the agency or its social workers to second-guess a doctor's decision to prescribe medication.
The boy was prescribed amitriptyline to quell his hyperactivity and sleeplessness. He died of amitriptyline poisoning.
The story of Domico's troubled life and death was featured in a Post-Intelligencer series that examined shortcomings in state oversight of foster children prescribed powerful psychotropic drugs.
The series found that concerns about psychotropic drugs had prompted one state, New Hampshire, to prohibit their use on all foster children. Another 24 states required that the biological parents of foster children either give their consent or be consulted before prescriptions were written.
Dr. Daniel Stowens, the Seattle neurologist whose medical license was suspended after Domico's death, said this week that he'd assumed the state had safeguards in place and that the boy was being seen by a pediatrician.
That was not the case. When Domico died April 21, 1996, he'd gone more than a year without seeing another doctor.
Stowens treated dozens of Medicaid-covered foster children after opening his Laurelhurst pediatric neurology office in 1993. But he said in an interview that he had misjudged the child-welfare system's ability to protect such children.
He said he realized only after Domico's death that state officials were not matching troubled or fragile children with foster parents capable of properly administering potent medications.
"I assumed that there was some supervision of the foster home," Stowens said.
"I assumed that there were case managers acting as advocates for children who would pull a child out of a home if there were some reason to worry about the foster parent," he said. "I assumed they had some way of determining which foster parents can handle medically fragile children."
Washington's new policy, borrowing language from a 3-year-old Oregon law, defines psychotropic medication as any drug intended to "affect or alter thought processes, mood, sleep or behavior," including Ritalin, Prozac and lithium.
If a parent or legal guardian is unwilling, unable or unavailable to consent to a medically necessary psychotropic medication, social workers can obtain a court order for it, probably in juvenile court. Oreskovich said letters would soon go out to judges around the state.
The rules will apply to children now coming into the system. Children already on parent-approved medications must get their approval for any change.
Legislators had called on DSHS to implement the changes in the wake of the P-I series.
Both DSHS and Stowens, 49, are defendants in a lawsuit by Domico's mother.
The Medical Quality Assurance Commission withdrew Stowens' right to treat behavioral problems in November, then suspended his medical license altogether in February for his alleged failure to transfer all his psychiatric patients to other doctors by the deadline.
The state Department of Health charged Stowens with endangering patients by frequently exceeding maximum recommended doses for potent drugs such as amitriptyline, an anti-depressant better known as Elavil.
Stowens said it is appropriate for a specialist like him to sometimes exceed standard guidelines when normal doses aren't effective.
He said not one of his patients had been harmed by taking medicines at the doses he'd prescribed.
The state also said Stowens had not ordered the electrocardiograms and blood tests recommended by textbooks when giving children high doses of hazardous drugs. Stowens said those books are written with the authors' legal liability in mind, and his experience and recent research show the tests they recommend don't predict which patients will have problems with the drugs.
A five-member medical disciplinary panel will review the merits of the charges against Stowens next month.
Lyle Quasim, head of DSHS, has blamed many of the medical problems cited in the P-I series on Stowens. He treated three of the 15 children featured in the series.
The fatality review committee that examined Domico's death also found that DSHS:
-- Lacked procedures to monitor the appropriate use of psychotropic medications.
-- Lacked procedures for correlating the needs of a child with the skills of a foster parent.
-- Kept records on Domico that were "disorganized, incomplete and at times illegible and/or duplicative."
Oreskovich said dramatic improvement will come with implementation in January of a $4.5 million foster children health "passport" program. Public health nurses will compile medical records that stay with children as they move around.
The agency also received money from the Legislature to add about 100 social workers and supervisors, plus a corps of recruiters and liaison workers to keep foster parents and attract new ones.