6-YEAR-OLD DIED WHILE IN STATE'S HANDS
Steven Goldsmith
Domico Presnell never chose his drugs - not the cocaine that quickened his newborn heart, nor the prescription pills that stopped it six years later.
Yet, though he grew just 3 feet, 8 inches tall, Domico left an imprint on Washington's $154 million-a-year child welfare system.
His death last April at age 6 in a Seattle foster home may prompt state officials, for the first time, to monitor the flow of potent prescription mood medications to foster children.
Domico's mother - homeless and addicted to crack cocaine - thought when she surrendered her son and his sister to the state in 1994 that the foster care system would protect them.
"I thought foster care was in their best interests," said Carolyn Presnell, who gave birth to Domico on Valentine's Day 1990. "I couldn't take care of them."
Under the state of Washington's care, Domico's rotted teeth and inflamed skin went untreated. But taxpayers supplied him with four different prescription drugs - all to control his behavior.
Today, Presnell takes her guilt and grief undiluted with drugs or drink. She has been clean for 18 months, is secretary of her Narcotics Anonymous chapter, works full time and is reunited with her daughter.
She is suing the state and Domico's doctor for their alleged negligence. But she acknowledges that by letting go of her children 21/2 years ago she exposed them to harm.
She wasn't alone.
Domico's foster mother, his doctor and social workers - all paid by the taxpayers to help Domico - failed to do the job.
The state took custody of Domico and his 3-year-old half-sister on Aug. 23, 1994. Presnell had disappeared four or five days before, leaving her offspring with her homeless 15-year-old sister. The policewoman who took the youngsters to Child Protective Services wrote, "Both kids in extremely poor shape, no shirts, hungry, dirty."
That autumn, Domico and his sister were shuttled through four foster homes. In one, a child was being investigated as a sex offender. The fourth was a 30-day receiving home where the pair stayed 60 days.
On Dec. 20, 1994, social workers finally found a foster parent willing to take the children, Wanda Pharr.
Pharr, 40, had completed her foster parent training that spring and already had a foster daughter sharing her two-story Leschi home with her two teenagers.
But within two days of getting Domico and his little sister, Pharr was having problems. The girl was sexually "acting out" with Domico at night, Pharr told the social worker, and Domico had thrown a tantrum on Christmas Eve and stopped up the toilet.
Two days after Christmas, Domico locked himself in the bathroom and this time bashed the toilet with a hammer. When he couldn't find his favorite television channel, he knocked over the TV set.
Even worse, he tended to wake up at all hours.
"Both children need close supervision," his dossier noted.
State foster care social worker Monica Tate put the children on a waiting list for an intensive therapeutic preschool. By late January, they were still waiting.
On Jan. 24, pediatrician Melanie Ito at Columbia Health Center wrote that she was "very concerned about both children, and have told the foster mother that both children need mental health services."
As January gave way to February, the children continued to wait for therapy. In March, Domico smeared pizza on the wall, and Tate suggested "medication for anxiety and depression." She recommended Dr. Daniel Stowens, a child neurologist known for his willingness to treat foster children.
Stowens had a knack for putting his young patients at ease before turning to the grown-ups who had brought them in. He made monthly trips from his Laurelhurst office to Yelm and Pasco to treat children with serious brain disorders ranging from retardation to cerebral palsy.
At least two-thirds of his patients were low-income children from the Seattle area whose bills were being paid by Medicaid and whose main reasons for being sent to the doctor were behavioral.
Domico joined the list on March 31, 1995.
"When I first saw him it appeared he had been neglected," Stowens said in an interview last summer. "Every interaction that he had with another person either made him cry or made him angry to the point where he would hit, bite, kick."
After his first encounter with Domico, Stowens dictated for his file an admission of uncertainty.
"At this point, it's very hard to know how much of his anxiety is an expected normal reaction to his life's experience, and how much is biologically determined."
Stowens started the boy on amitriptyline - the same anti-depressant, he testified later, that he prescribed to slightly under half of his 190 child Medicaid patients.
Like many drugs that have not been widely tested on children, amitriptyline is recommended by the Food and Drug Administration only for patients 12 and older. But doctors often prescribe outside those guidelines, and amitriptyline has been used for three decades to treat bed-wetting, hyperactivity and depression.
Just as Domico started taking amitriptyline, he and his sister entered a therapeutic preschool at Seattle Mental Health Institute - seven months after becoming wards of the state.
Alysone Warren, manager of Domico's preschool, said he was among a half-dozen pupils who had entered the school while being given potent psychotropic medication.
"We were all shocked how in the last couple of years we were getting really young children on this medicine," she said. "We joked that we were detox for preschoolers."
Three afternoons a week, counselors at Seattle Mental Health worked with Domico on his temper and concentration. Unless he was doing martial arts, he rarely focused on anything for long.
By July 6, Stowens had boosted Domico's daily amitriptyline dose to 75 milligrams, but he still could not say for certain why the boy remained sleepless and unruly.
"The underlying reasons for his behavior still remain somewhat obscure," Stowens wrote.
In September, Domico's sister was sent to stay with another foster mother, but Pharr was not finding him any easier to handle, according to letters she sent to the social worker.
While eating a sandwich at school on Dec. 4, Domico suddenly grabbed his jaw and exclaimed, "Ow!" His baby molars had rotted down to stubs.
A few weeks later, when Brian Cruess, Domico's favorite counselor, examined a suspected ringworm rash, Pharr accused him of molestation and pulled Domico from Seattle Mental Health. A social worker later wrote that Pharr admitted the accusation was payback for what she felt was Cruess' criticism of her parenting skills.
"Most of the kids get so much better," Warren said. "Domico ... after a year, he was not any better; he was worse."
By late February 1996, concerns about Domico had spread to his special-education kindergarten teacher at Colman Elementary School, who wrote Tate a note saying: "I've noticed a lot of changes in Domico's mood and behavior. I would like your input on these issues."
Pharr was worried about what she called Domico's "spells." Three or four hours after taking his medicine, his legs and arms would occasionally get stiff and his eyes would roll back, she told a state investigator after his death.
Pharr said she told Stowens about the spells, and he assured her they were not seizures.
In addition to the 125 mg of amitriptyline Domico was now taking every day, he also had a prescription for clonidine, an anti-hypertensive drug prescribed to quell impulsiveness.
On March 4, Stowens wrote that he was abandoning Domico's clonidine and adding pemoline, a stimulant to boost concentration, "in anticipation of weaning him off his current medicines in the very near future."
Domico had less than two months to live.
When Warren, the Seattle Mental Health supervisor, visited Domico at school that week, she was shocked.
"He was glazed over, shuffling," she said. "He looked so different than when he was in our program."
A school speech pathologist told Pharr he was worried about Domico's hand tremors, tongue chewing and the increase in his negative behavior at school.
The boy's biological mother was concerned, too. Working at a downtown juice bar and drug-free for seven months, she was preparing to bring both her children home. A hearing on when she could regain custody was scheduled for May.
A counselor noted that on "a very warm, loving family visit," Presnell praised Domico's drawing and writing, and "he beamed." But Presnell also noticed while he was drawing that "his hands would shake really bad."
On April 10, 11 days before his death, Stowens canceled the pemoline and added the seizure medicine carbamazepine, better known by its brand name Tegretol, "to see if we can reduce his aggression and maybe his sudden intense mood."
Stowens had tapered the amitriptyline back to 100 mg - still near the top dose recommended by the American Psychiatric Association and the FDA for Domico's weight of just under 50 pounds.
On April 16, Domico told Presnell that he loved her and asked if he could come back home "in four years."
During the next week, Domico's spells seemed to be getting worse, Pharr told investigators. She left several messages on Stowens' answering machine, but said he didn't call back.
On April 20, Domico spent the afternoon at his foster grandmother's house, playing in a tent in the back yard. Pharr told investigators she gave him his amitriptyline pills that afternoon before he went back out to play.
Driving home that night, Domico had a spell in the car, according to a declaration submitted by Lynn Larsen-LeVier, an investigator for the state Department of Health.
Domico suddenly threw off his seat belt, forcing Pharr to stop the car and hold on to him. Later at home, a groggy Domico lay snoring on the floor, and Pharr covered him with a blanket, thankful he was getting some rest.
He never woke up.
Presnell had just come home from a Narcotics Anonymous meeting the morning of April 21 when the phone rang with the news of her son's death.
At Pharr's house in Leschi, social workers and family members were joined by King County Medical Examiner Donald Reay. A few weeks later, his staff ruled that acute amitriptyline poisoning had killed Domico.
State investigators pored over Stowens' records and identified six children who had been getting doses of amitriptyline higher than recommended by medical textbooks and without the usually recommended safety checks, such as an electrocardiogram to analyze heart function.
"I would want an EKG for my child," said Paul Wender, a professor of psychiatry at the University of Utah who testified during the investigation.
Stowens responded that research published in the journal Pediatrics and elsewhere showed that blood tests and EKGs did not help predict problems.
Wender said most doctors use less risky types of drugs on young children: stimulants for hyperactivity, and selective serotonin reuptake inhibitors (SSRIs) for depression.
Dr. Bill Robertson, a toxicology expert at the Washington Poison Center, testified last month that Domico probably had swallowed three to 10 times the prescribed daily dose of amitriptyline the night before he died.
"There's no way an individual could have been walking around with that level in the bloodstream," Robertson told the state Medical Quality Assurance Commission, which is considering whether to pull Stowens' license to practice medicine.
Stowens' attorney, Thomas Fain, said that clears the doctor of guilt in Domico's death, other than as a scapegoat.
"The person dispensing the medication was a foster parent assigned by the state," Fain said. "The state started looking for someone else to put the blame on, and went to Dr. Stowens."
But the Health Department investigator said Pharr insisted there was no way Domico could have gotten extra pills, and Dr. Christopher Varley, a physician called by the state, called the evidence about an overdose "inconclusive."
Furthermore, Assistant Attorney General Ed Newcomer called amitriptyline "a second-rate drug" that had been used recklessly by Stowens. Newcomer is seeking to bar Stowens from practicing medicine.
Stowens denied responsibility for Domico's fatal drug poisoning in interviews with the Post-Intelligencer last year and in the recent hearing on his license suspension.
The state has suspended Pharr's right to take in more foster children until the questions are cleared up, and she declined requests for an interview until the investigation is over.
A panel of outside experts reviewing Domico's death recommended late last week that the state improve the training program for foster parents and the tracking system for the psychotropic drugs they give their wards.
The Department of Social and Health Services is reviewing the findings and may act by summer.
Domico's mother is suing both Stowens and the state.
"The state's liable no matter what," said her Seattle attorney, Sim Osborn. "He got the wrong drugs and bad care."
Domico's drug history
Feb. 14, 1990: Domico is born at University Hospital in Seattle to Carolyn Presnell, 19, and a father in a Florida prison. Her urine test shows positive for marijuana and cocaine. Domico is noted to be extremely jittery, with poor respiration, but is not determined to be suffering from neonatal withdrawal syndrome.
March 31, 1995: Dr. Daniel Stowens prescribes the anti-depressant amitriptyline for the 5-year-old Domico. Initial dosage is 10 milligrams, but that is soon increased to 20 mg. The medication's side effects include dry mouth, constipation and cardiovascular problems. Medical guides indicate the drug is not recommended for children under age 12.
July 6, 1995: Amitriptyline dosage is increased to 30 mg.
Oct. 3, 1995: Amitriptyline dosage is increased to 100 mg, and clonidine, used to treat hyperactivity and attention deficit disorder, also is prescribed. Clonidine's side effects include sedation, headache, nausea, dry mouth, constipation, joint pain and hepatitis. Its safety in children has not been determined.
March 4, 1996: Amitriptyline dosage is maintained at 100 mg, and clonidine is stopped. Doctor suggests adding pemoline, a psychostimulant, "in anticipation of weaning him off his current medicines in the very near future." Side effects of pemoline include reduced appetite and liver inflammation. It also can be habit-forming. Its effectiveness in young children has not been determined.
April 10, 1996: Amitriptyline dosage is maintained at 100 mg, but pemoline is stopped because it gives Domico tic-like movements. Carbamazepine, used to treat manic activity and convulsions, is prescribed, 100 mg a day. Side effects of carbamazepine include double vision, drowsiness, poor coordination, mild nausea and reduced white blood cell count. Its effectiveness in young children has not been determined.
April 21, 1996: Domico fails to wake up. He is last seen alive at about 1 a.m., lying prone on the hall floor in the doorway to his bedroom. Cause of death is attributed to acute amitriptyline intoxication, pulmonary congestion and edema, and cerebral edema.