The Post-Intelligencer's six-month investigation of the way foster children are prescribed powerful psychotropic drugs found that Washington's lack of safeguards put youngsters at risk.
Child welfare experts said that inappropriate medicating also can be a symptom that public officials are failing to perform the task taxpayers hired them for: watching after kids.
Foster children, they said, did not ask for the childhoods they are having - did not ask the people who brought them into the world to beat them up, check out on drugs or liquor, molest them, fall ill or maybe just fall apart.
Government cannot save every child whose family hurts or fails him. But here are four suggestions for reducing foster children's medication risks gleaned from more than 120 interviews with foster families, social service experts and health professionals.
Some of the suggestions are similar to those released late last week by an outside panel of experts who reviewed the death of 6-year-old Domico Presnell and called for major improvements in record-keeping, training and monitoring for foster parents and Department of Social and Health Services staff.
Remedy 1: Get a second opinion
Foster children are entitled to state-of-the-art medicine, but they also may need more safety precautions than children who live under a birth parent's wing.
The Oregon Legislature passed a law in 1993 requiring that all adults with a legal stake in a foster child's life - caseworkers, lawyers, foster and biological parents - be notified when the child is given behavior-altering drugs.
The Bobby Jackson Law lets a juvenile judge step in if there is evidence that drugs are doing damage. For at least some children, the law is making a difference, foster parents say.
California tries to guarantee a second opinion by requiring juvenile court judges to approve psychotropic prescriptions.
"It gives us and the court some ability to spot clinics or physicians that maybe don't use the best practices," said John Tobin, a clinical social worker with Los Angeles County Mental Health. "If they're running some kind of medical mill, we'll quickly catch on."
While this can curb the overdosing of some children, Tobin said, it can work the other way, too. An expert reviewer sometimes persuades an anti-drug judge or attorney to give certain medicines a try.
One major gap in California is enforcement. Thousands of doctors never bother to fill out the forms, Tobin said. In 1995, he and his colleagues checked psychotropic prescriptions for 2,157 Los Angeles foster children - which he said was probably fewer than half the number actually dispensed.
Nancy Shay, director of Mental Health Advocacy Services in Los Angeles County, said the lack of enforcement endangers children.
"For the most part," she said, "the doctors doing a good job of complying are the ones who'd do a good job being careful, anyway."
Another potential check against drug problems is to require the consent of a child's biological parents or legal advocates, as half the states do.
In Washington state, foster parents - not judges, advocates or birth families - provide the consent, said Noella Rawlings, an assistant attorney general at the Department of Social and Health Services.
Remedy 2: Just say no
For Rose Bailey, becoming a Seattle foster mother meant sharing her home with a traumatized, hyperactive 31/2-year-old who couldn't stand to be touched or bumped.
Before reaching for Ritalin, Bailey tried weekly visits from an occupational therapist, who gradually trained the boy, through kneading bread and other tactile exercises, to "calm his body."
The youngster never did need prescription psychotropics and, at age 9, gets good grades and is a permanent member of the family.
Not every child would respond the same way, but Bailey hopes others get the same chances. "My feeling is, every kid in foster care ought to be in some kind of therapy."
At Vista del Mar Child and Family Services in Los Angeles, therapy is required and drugs are a last resort. To staff psychologist Elias Lefferman, emotions suppressed with medication are bombs that can erupt years later as alcoholism, violence or an inability to form relationships - a syndrome known as attachment disorder.
"It's like covering up a pain in your side with an analgesic," Lefferman said. "We need to find out what is the pain telling us. I don't want to say all these kids shouldn't be on medication. I just think medication is too easy. If a child is calm, we think he's cured."
Innovation can replace drugs. At the Progressive Life Center in Washington, D.C., more than half the children who show up are on psychotropic drugs. Within a year, nearly all are off.
Children themselves select the families they will live with after viewing videotapes. In-home therapy begins as soon as the child arrives in the private, non-profit program. Three-quarters of the youngsters get better emotionally.
One ingredient is the use of African cultural rituals with the center's almost entirely black clientele. Tailoring the healing to the kids often gets results.
Foster children in rural Central Washington state flourish through therapeutic horseback riding, said Walt Gearhart, the Medicaid mental health administrator.
Working with street teens in Seattle, Street Links coordinator Greg McCormack said, he does his best therapy during games of hackeysack.
"Anything but sitting in a sterile room asking, `Johnny, how did you feel when your stepfather abused you?"' McCormack said. "Not enough therapists know how to do therapy that's action-based."
Innovation often costs less than traditional office visits.
Dr. Charles Huffine, mental health medical director for King County, said he achieved one of his biggest breakthroughs with a troubled teen while on a therapeutic camping outing. When the moment of catharsis arrived, both the psychiatrist and patient were up to their necks in a lake.
Remedy 3: Expect excellence
The challenge of foster parenting doesn't get easier as more children enter the system with severe problems - including mental retardation and cerebral palsy - which in another era might have sent them to an institution.
"It's hard to recruit foster parents who have the time, energy and the setup so they can do this," said Paula Oppermann, DSHS Children's Services manager for North Seattle.
Yet finding devoted foster parents and giving them the training and tools are the most important measures to protect kids, said Mark Simms, a pediatrics professor at the Medical College of Wisconsin.
"The therapist should be working with the foster parent, should be a coach for the foster parent," Simms said. "What they do is cut these people out and say they're just baby sitters."
In a survey last fall, nearly one in four of Washington's foster parents said that at least some of the time they were not treated with respect by a social worker.
Remedy 4: Shine more light on system
Within weeks after Domico Presnell died while under state care, officials convened an 11-member review panel to find any systemic problems that might have led to his death. The group included three physicians, two social workers, a foster parent and a police detective.
These experts met a dozen times to probe major public policy issues. All the meetings were behind closed doors. The public that paid for the child welfare system was not allowed to explore where it went awry until the panel selected by King County's regional children's services administrator had wrapped everything up.
"We're looking at confidential medical issues," said Jeff Norman, the DSHS manager coordinating the review.
While a youngster's privacy is important in child welfare, greater disclosure of the way the bureaucracy works could improve accountability, raise public interest and educate those who pay the bills for the system.
Foster parents' contracts and state law forbid them from revealing even the name of a foster child to anyone but a care provider. However, many aspects of the system - such as dependency hearings, policy committees and fatality reviews - could be opened to public view without compromising confidentiality.