MEDICATING FOSTER CARE
PRESCRIPTIONS GIVEN TO CHILDREN ARE SOARING OUT OF STATE CONTROL
March 31, 1997
One out of every five children in Washington state's foster care system is on potent mood-altering medications. Yet the state has no safeguards to protect the children who swallow these sometimes toxic pills.
As a result, foster children have suffered hallucinations, loss of bowel control, abnormal heartbeats - even death.
The state does not chronicle the problems children experience with these drugs. Officials aren't even sure how many of their troubled wards take behavioral medications, a six-month investigation by the Seattle Post-Intelligencer found.
Foster parents are given virtually no special training for handling the drugs. And there is no requirement that a child's biological parents or family members be told about the medications.
In 1992, records show, 19 percent of the children who entered foster care received prescriptions for psychotropic medication paid for by the state of Washington. Foster children were 10 times more likely to be given mood-altering drugs than other children whose medical bills were paid with tax dollars.
Health professionals say the number of foster children getting drugs has grown since 1992, but the state stopped keeping count five years ago and has no idea how many foster children are being drugged or what drugs they are taking.
While the numbers are fuzzy, the consequences are clear:
-- A 4-year-old girl was rushed to intensive care with an erratic heartbeat after her foster parents accidentally doubled her daily dose of anti-depressants - a dose already far above the maximum recommended for her age and weight. The foster parents said neither their doctor nor social worker had warned them of the hazards of the drug, amitriptyline.
-- A 5-year-old boy tried to kick out the windows in a bus, covered himself with feces and tried to run naked down the street after being given powerful anti-depressants. His foster mother said she never was warned of the side effects.
-- A 13-year-old boy sent into foster care in 1995 during the Wenatchee sex-ring trials heard voices and suffered memory loss after being put on high doses of the anti-depressant Zoloft. He later tried to kill himself.
-- Domico Presnell died. The wavy-haired 6-year-old failed to wake up in his Seattle foster home last April 21. A toxic level of amitriptyline was found in his blood.
Two months earlier, Domico's caseworker at the Department of Social and Health Services, the agency in charge of foster care, had sought to intervene. Social worker Monica Tate wrote in the Service Episode Record of her "concern of children on my caseload, including Domico, being prescribed medications for their behavior, i.e. Ritalin, Amitriptyline, etc., without my consent." The state, she said, lacked "policies, rules and regulations" for monitoring such medications.
Nearly a year after Domico's death, DSHS still hasn't adopted a drug policy to protect children in foster care.
Rosie Oreskovich, head of the DSHS Children's Services division, said the agency is considering changing some drug policies in light of Domico's death, but doesn't want the job of second-guessing doctors.
"This case makes it very clear to me that there are some things in our system we can improve," she said. "But to say that this death is the result of what Children's Services did or did not do is wrong.
"I can't be in a position where I have social workers reviewing the work of a physician," said Oreskovich, whose division runs foster care for the state. "They don't have the medical training."
However, Michael Mirra, an attorney with Columbia Legal Services, a public interest law firm, said foster children depend on the state for their safety. "When the state presumes to take a child into its care, it incurs an enormous obligation," he said.
The lack of state laws or guidelines not only leaves social workers largely helpless to guide foster parents, but the children's biological parents and grandparents also have no way of knowing what kinds of drugs the children are getting.
"I would have never had my son put on medications," said Carolyn Presnell, Domico's birth mother.
Many children benefit from the growing array of medicines that target mental disorders. But parents can keep an eye on their children's reactions to drugs - and might even seek a second opinion - while a foster child's side effects sometimes get overlooked in the shuffle from home to home.
"I've seen too many holes in the medical records of foster kids," said Maxine Hayes, chief of child and maternal health for the state Department of Health.
That's why a growing number of states have taken extra steps to protect foster children.
Oregon passed a law in 1993 after the sudden death of 7-year-old Bobby Jackson from prescribed anti-depressants at his Eugene group home. The law requires that caseworkers, parents and other involved adults be notified when a child in state care is prescribed behavioral drugs.
In California, a judge must approve giving psychotropic drugs to any foster child. Dr. Michael Malkin, who reviews the drugs for Los Angeles County judges, said that deters doctors from dispensing risky anti-psychotic drugs en masse.
"The psychiatrist is usually beseeched by the group home operator to medicate the kids," said Malkin, who tries to substitute milder medications that don't cause permanent facial tics, heavy sedation and other side effects.
In Washington, psychotropics - stimulants, sedatives, anti-depressants and anti-psychotics - flow unchallenged from doctors to wards of the state.
A committee of outside experts convened by DSHS to look into Domico's death recommended late last week that Washington consider adopting laws similar to those in Oregon and California.
DSHS Secretary Lyle Quasim referred questions on the department's policies to Oreskovich. She said the agency is trying to improve its tracking of drugs and medical care but doesn't see the need for new laws to mandate such action.
"I don't necessarily think legislation all the time is a quick fix," she said.
Washington state officials don't know how many foster children take behavioral drugs. The most recent reliable statistics date to 1992, when psychotropics were dispensed to 1,528 foster children.
The ranks of foster children being given psychotropic drugs have swelled since then, experts say.
"When I see foster children, most of them are on a stimulant, anti-depressant or anti-psychotic - or usually all three," said Aija Guedel, who was president last year of the School Nurses Organization of Washington.
Yet Washington state's 6,342 licensed foster parents are given little training in the drugs and their side effects. The topic is folded - along with firearms and fire exits - into general health and safety, one of 35 subjects covered in a 12-hour orientation class. A subsequent 60-hour foster-parenting course discusses medications, but the emphasis is on meeting legal requirements. And the state has none for psychotropic drugs.
Foster parent classes touch on the anxiety and anger that often buffet children separated from their birth parents, especially after sexual abuse or other horrors. Pills by themselves can't mend those wounds, according to the American Academy of Pediatrics, whose policy is that "medication should never be considered the complete treatment program."
Yet the Post-Intelligencer found cases in which behavioral medication - costing as little as 2 cents a tablet - seemed to be the only service provided in abundance, while therapy and other support for foster parents and children were tightly parceled out.
For example, as wards of the state have been given more behavioral medicines, their access to therapists has shrunk.
In King County, money to treat the most emotionally disturbed poor children was chopped in half last year after the county switched to a private company to manage its mental health program for Medicaid recipients. The reductions were imposed over sharp protests from such professionals as Children's Hospital psychiatry chief Eric Trupin, who fired off a letter predicting that the "draconian" cuts would "create a catastrophic collapse of access to the most at-risk children in the system."
The non-profit Children's Justice Center, an advocacy group based in Seattle, is considering suing Washington state to fight the cutbacks in mental health services.
Another failing that puts kids at risk of drug disasters concerns the seemingly simple area of record keeping.
When Domico Presnell went to see Dr. Daniel Stowens on March 31, 1995, the Laurelhurst physician wrote in his notes that "little is known about his past medical history."
That was nearly a decade after the Child Welfare League of America, which sets accreditation standards for agencies that deal with children, recommended that states give foster children "health passports" carrying crucial and up-to-date medical information to each caregiver.
San Diego has used such passports for 10 years. When a child enters foster care, nurses find and review his or her entire medical record, noting any problems requiring social worker follow-up.
Washington's legislative budget writers last week killed a proposal from DSHS and Gov. Gary Locke to spend $6.6 million to set up a similar system here. Children's advocates have vowed to revive it.
"It only makes sense to have the information follow a child," said Rep. Suzette Cooke, R-Kent, a House sponsor.
Spotty communication isn't the only problem.
Uprooted children are rushing into Washington's foster care system so quickly, the state can't keep up. More than 10,000 children are in foster care, and half have been waiting longer than a year for a permanent home.
Part of the delay is because social workers trying to resolve knotty questions about Washington's families juggle a workload of nearly 40 children each - double the standard set by the Child Welfare League of America. A proposal to add about 50 social workers was rebuffed by legislative leaders last week.
When psychotropic drugs flow into this overloaded system, the mix is volatile.
Foster parents remain in the system who may lack the skills to follow complicated instructions, said Maggie Kennedy, associate director of Childhaven, a Seattle treatment program. "Ritalin can help in some cases," Kennedy said. "But we don't give it to people who are unsophisticated in following the directions."
For each child a foster parent takes in, Washington state sends out a monthly check of at least $303. About half the time, that does not cover the expenses of caring for the child. Still, foster children say they sometimes feel more like a meal ticket than a family member.
One child, Miranda, encountered both kinds of foster homes during her six years as a ward of the state: havens of affection and way stations of indifference.
Lifelong abuse by her father sent her to her first foster home at age 11. When she was 15, she threatened to kill herself because Child Protective Services sent her back home against her will. "I became suicidal because it didn't feel like anybody was protecting me," she recalled. The threat led to a 72-hour involuntary hospitalization in Everett.
"I'd felt a loss of control before, and now they just completely took control away," she recalled of being committed. "They put me on an anti-anxiety drug, Ativan."
Despondent and stuck in an unpleasant shelter home, she soon found herself back in the hospital on the anti-psychotic drug lithium. "I gained 30 pounds in two weeks, mostly water," she recalled. "I remember shaking. I had hallucinations one night, like seeing ghosts and colors and kind of like spots."
She was sent home on the anti-depressants Xanax and later Pamelor.
"During one period, my foster parents wouldn't refill my prescription, and the withdrawal was awful," she recalled. "It felt like the flu, nausea."
Released from foster care three years ago, Miranda, 20, now attends a community college and works with homeless youths.
"I'm feeling happy with my life," she said. "But I'm angry they put me on these drugs. They couldn't say my parents were the problem; they had to say, `It's this kid!"'
Foster parents say the best training and intentions can be overwhelmed by the child who walks through the door. Those who succeed must be ferociously assertive.
"I've gotten into everyone's face and said, `I will be damned if this placement is going to fail for lack of services!"' said Jean Freeman, who took 8-year-old Lawrence into her Crown Hill home last year.
The boy had never really been toilet-trained by his drug-addled mother or two previous foster parents, and the slightest cross word from a peer or teacher triggered violent fits.
Lawrence made progress in a special day-treatment program at Children's Hospital for children unable to cope with regular school, but budget constraints limited his stay in the program.
To help him keep his emotional balance in school, Lawrence recently began taking a low dose of Ritalin - but only after Freeman first got him into a special behavioral classroom and two kinds of therapy.
"I've had him for six months," she said, "and we're just starting to get everything he needs on line."
Decades of scholarly studies show that from 35 percent to 85 percent of foster children suffer from emotional or mental impairment. How to respond is the question.
Without support for tough children, foster parents often turn to the pill bottle, said Dr. Neal Halfon of the University of California at Los Angeles, one of the most widely published researchers on foster care.
Halfon said doctors confront a dilemma when a foster child walks into the clinic. Behavior-calming drugs might keep the youngster from getting kicked out of a good, stable home. Yet that brings a risk of long-term emotional and physical damage, he said, especially when a preschool child is taking three or four powerful drugs at a time.
"Kids are being overly medicated with uncertain diagnoses," Halfon said. "The question is whether or not it's just chemically warehousing children."
The ranks of foster children are growing, and so is the number of drugs taxpayers pay for to keep them calm. But the state doesn't regulate the drugs, and some of them can be harmful.
Foster child Domico Presnell never chose his drugs - not the cocaine found in his system when he was born, nor the prescribed anti-depressant that resulted in his death six years later.
In a sweep of an alleged child sex ring, Wenatchee police sent the youngsters to the supposed safety of foster homes. For at least a third of those children, foster care meant a dose of drugs.
The death of 7-year-old Bobby Jackson due to anti-depressants changed the way drugs are given to foster children in Oregon, and also gave natural parents some rights.