Lawrence coos and gurgles, patiently trying to coax his foster mother's yellow-headed parrot to let down its guard.
Many people are trying to get Lawrence, a 9-year-old cast aside by an abusive father and drug-addicted mother, to do the same.
But intensive therapy for Lawrence and children like him has gotten scarcer, while money for behavioral drugs continues to flow, infuriating health professionals who believe drugs alone aren't the answer.
"This kid's life is not going to get fixed up by medications," said Barbara Kleine, supervisor of a program at Children's Hospital that for a time provided Lawrence with daily counseling. "It's just a long haul of people being there."
Providing the people and programs to help troubled children is getting harder. In the past two years, King County has chopped in half the money available for mental health services for severely disturbed children, many of whom are in foster care.
The cutbacks were made after the county switched to a managed care mental health company, which pays providers a set amount for each patient to encourage the most "efficient" treatments.
Drugs are less expensive than therapy.
The psychotropic drug most often prescribed to Washington's foster children over the past five years has been methylphenidate, or Ritalin, which cost the state about 17 cents per pill, according to the 1996 Formulary and Drug Use Guidelines used at Western State Hospital.
The second most common pill for foster children was the anti-depressant imipramine, costing about 2 cents a dose.
A survey of 360 psychiatrists and psychologists in December 1995 found that reliance on drugs has increased "greatly" or "somewhat" under managed care.
"The easiest therapies are the medicines," said Dr. Ken Feldman, director of psychiatry at Seattle's Odessa Brown Children's Clinic. "The harder thing is to use behavioral techniques effectively.
"Sometimes," he said, "you end up doing what's possible."
The economics of the system not only favor drugs over more expensive therapy, they also favor prescriptions of older, potentially riskier anti-depressants. Newer drugs to treat depression and hyperactivity, known as SSRIs, can cost 10 times as much as an older class of drugs called tricyclic anti-depressants.
One tricyclic, amitriptyline, was implicated in the death of 6-year-old foster child Domico Presnell last year. Another, imipramine, was blamed in the death of a 7-year-old Oregon foster child, Bobby Jackson, in 1993. A third, desipramine, has been linked to at least five children's deaths.
SSRIs, or selective serotonin reuptake inhibitors, which include Prozac and Zoloft, pose a lower risk of heart problems to children and don't require as much monitoring, physicians testified at a hearing last month on the doctor who treated Domico.
Yet during the past five years, SSRIs were prescribed to Washington foster children less often than the tricyclics imipramine and desipramine.
Many professionals who work with foster children see managed care as a threat.
"With money for actual therapy services drying up, there is more medication," said Diana Kronstadt, foster care project director at the Center for the Vulnerable Child in Oakland, Calif.
When Lawrence first came to Kleine's day treatment program at Children's Hospital last spring, he had not been toilet-trained. Bright and often winningly affectionate, he suddenly would burst into violent profanity at the least upset. (Out of privacy concerns, only his middle name is used in this story.)
The program, part of the hospital's psychiatry department, specializes in working with children who can't cope with school. Children's enrolled Lawrence in a sort of human behavior class, with counselors teaching him everything from earning rewards to using the toilet.
At Children's day treatment program, kids who come in taking psychotropic medication usually get their dosages reduced or stopped, Kleine said.
Two months after he started, Lawrence was back in public school. Children's had to reduce how long kids can stay in treatment because of cutbacks in Medicaid payments.
Lawrence recently was put on methylphenidate, which, like other psychotropic drugs, is paid for out of a separate Medicaid bankroll and continues to be readily available whenever a doctor writes a prescription.
Dr. Charles Huffine, King County's mental health medical director, said the system does not push providers to rely on medication; it allows them to tailor treatments to a child's needs.
In theory, lump-sum payments per child give clinics room to be flexible and creative.
But theory crashed into reality after the county switched to a managed care program run by U.S. Behavioral Health of California for mental health services for Medicaid recipients. Two years after the switch, the system had to dig out of a $10 million budget hole because patients needed longer treatment than predicted.
Smaller agencies specializing in children protested that managed care was punishing those who needed care the most. "Maybe we should call it mangled care," said David Cousineau, executive director of Seattle Children's Home.
Eric Trupin, director of the psychiatry department at Children's Hospital, said the cuts especially threaten the day treatment program that was getting Lawrence ready for school.
"Managed care in itself is not a villain," Trupin said. "But many of us are troubled by the decrease in funding for high-intensity kids. Day programs are difficult to come by; they're expensive. What I'm afraid of is we're going to see more kids put in the hospital."
When Lawrence left Children's for the last time, his foster mother, Jean Freeman, said it took 21/2 months to get him plugged into counseling through Catholic Community Services and Seattle Children's Home.
Because of Lawrence's special needs, Freeman gets a monthly check of $814 from the state, rather than the base foster-parent rate of $374. But she said the money does not cover what she spends, especially not on such necessities as a cellular phone to respond to Lawrence's crises while she drives to work in Lynnwood.
Lawrence gets other help from taxpayers. He attends school with only five other children in a special behavior disorders classroom, courtesy of the Seattle School District. His special-education teacher is backed up for five hours a week by a mental health specialist sent by Seattle Children's Home.
However, to Freeman's unending frustration, there's no time-out room where Lawrence can cool down when he goes haywire, and no private bathroom for carrying out his toilet training regimen. Lawrence is not the only pupil in his kindergarten-to-third-grade classroom with such hygiene problems.
A foster mother for five years and a practicing Buddhist for 20, Freeman was reluctant to turn to drugs to treat Lawrence. The first week he took methylphenidate, he was kicked out of school for hitting another youngster, but Freeman and his teachers also noted improved concentration.
"It's not the cure-all," she said. "It just lowers things so you can still talk to him."
Freeman is determined to pull Lawrence through. Five years ago, when she realized she would never raise children of her own, she decided that her destiny was to do it for others.
Lawrence is teaching her what that means.
"This guy's been through a lot, and at such an age," Freeman said. "You can't get somebody who's never been safe and suddenly make them believe they're safe. When he's bad, it's, `Will you love me anyway?"'
`I can't wait till I see you. I going to do my best to make it home as soon a possible cause I getting home sick so I sitting there almost in tear while I am writing this letter.'
- Carl Cleveland, 14, of Ontario, Ore.,
in a letter to his parents a week before he died of antidepressant poisoning
They put me on desipramine. A week later they took all the kids in a van to the doctor. He spent five minutes talking to us, with the other kids in the room.
- Lyn Duff, 19,
San Francisco youth activist and former foster child
The easiest therapies are the medicines. The harder thing is to use behavioral techniques effectively. Sometimes you end up doing what's possible.
- Dr. Ken Feldman, medical director, Odessa Brown Children's Clinic
I was psychologically evaluated, and they said I had an anger problem. It was just that nobody would listen to me. They put me on Tegretol. It wigged me out. That's when Thorazine came in. I couldn't think. I couldn't talk. Toward the end, there was lithium, too.
- Jeffery John House, 27, former Seattle foster child
It's not unusual for me to have a child 9 years old on two or three psychotropic medications at one time.
- Dr. Sharon Collins, Mercy Medical Center, Cedar Falls, Iowa
The kid'll come to court nodding off. Teen-agers shouldn't be nodding off like that in that situation. They're zombied out. It's a real visible problem.
- Robert Stevenson, youth law attorney, Los Angeles
With money for actual therapy services drying up, there is more medication, which can be really inappropriate and doesn't deal with the sad, sad trauma of these kids.
- Diana Kronstadt, project director, Center for the Vulnerable Child, Oakland, Calif.
Medicaid cuts 1995-1997
The annual fee paid per child for treatment of serious emotional disturbances has been cut almost in half since 1995. In 1996, this program treated 545 children in King County.
SOURCE: King County Mental Health Division
Comparing prescription costs
The mood-altering drug most prescriped to Washington's foster children in 1992 was imipramine. While 330 foster children took imipramine, only 15 took sertraline. Imprimine belongs to an older class of drugs called tricyclics. Sertraline is in a category known as SSRIs. Though more expensive, SSRIs are considered far less prone to accidental overdose and don't require such careful safety monitoring.
Average cost per claim 1992-96:
SOURCE: DSHS Medical Assistance Administration
A Glossary of terms
Anti-convulsants: A group of drugs prescribed to treat or prevent seizures; includes carbamazepine and clonazepam.
Anti-depressants, tricyclic: A group of medicines used to treat mental depression; includes amitriptyline, clomipramine, desipramine and imipramine.
Anti-depressants, SSRIs: Selective serotonin reuptake inhibitors. A group of medicines that affect the absorption of the brain chemical serotonin; includes fluoxetine and sertraline.
Anti-psychotics: A group of drugs used to treat psychoses, such as schizophrenia and manic-depressive illness, anxiety states and severe behavior problems; includes carbamazepine, thioridazine and thiothixene.
Anxiolytics: Drugs that relieve tension or anxiety.
Attention deficit hyperactivity disorder (ADHD): A behavioral disorder characterized by overactivity, restlessness, distractibility, short attention span and difficulties in learning and perceptual motor function.
Depression: A mental disorder commonly associated with slowed thinking, decreased pleasure, decreased purposeful physical activity, guilt and hopelessness, and disorders of eating and sleeping.
Psychotropics: Group of drugs intended to affect or alter thought processes, mood or behavior; includes anti-psychotic, anti-depressant and anxiolytic medications and behavior medications.
Sedatives: Drugs that reduce excitement or anxiety.
Stimulants: Group of drugs that stimulate the nerves of the brain and spinal cord; includes amphetamine, caffeine, cocaine and methylphenidate.
Who to call
Information about behavioral modifiction drugs for children and about children with special needs.
Children's Resource Line
Children's Hospital and Medical Center, Seattle
Crisis Clinic of Seattle/King County
Foster Parents Association of Washington
Washington Advocates for the Mentally Ill
Learning Disabilities Association of Washington
Washington Protection & Advocacy System
State Department of Social and Health Services, Children's Services
National Association for Rights Protection and Advocacy
Legal advocacy in mental health.
Support Coalition International
Alliance on human rights in psychiatry.
Internet Web site: www.efn.org/~dendron