Portrait of a child at risk

Gabriel Myers had a charming little face with a big, toothy smile. In his photograph, he doesn't look like a 7-year-old who would kill himself in the bathroom of a South Florida foster home.

His buoyant air offers no hint of a child who threw such major tantrums that one of his caregivers feared for the safety of a baby in the home, ultimately sending Gabriel to a different family.

His photo bears no inkling of a boy who frequently "acted out" -- on other children -- the sexual molestation he experienced in the past.

It doesn't seem to be the face of a youngster whose short life was filled with the turmoil of a drug-addled mother, an absentee father and too frequent shuffling among distant relatives, schools and foster homes.

His eyes don't reveal a boy overwhelmed with stress, upheaval and disappointment.

And nothing in the photo suggests that this beaming child was on powerful, psychotropic drugs prescribed to rein in his diagnosed "mood disorder."

The photograph, in short, is a monument to the fact that appearances can be tragically deceiving -- and that interventions designed to help can hurt.

A downward spiral begins

With his mother bound for jail in June 2008, Gabriel entered Florida's child welfare system. There, documents indicate, he seemed to get responsive care, extensive counseling, frequent evaluations and medical supervision. But despite all this, his behavior began a downward spiral in October, generally worsened through the winter, and reached crisis stage by spring of this year.

Many of the boy's troubles paralleled the increased upheaval in his life, but his medication schedule is also of interest. In December he was prescribed Vyvanse, a stimulant for attention deficit issues, and initially showed improvement. But in early February, Lexapro -- an antidepressant -- was added; and in mid-March he was switched from Lexapro to Symbyax, an antidepressant/anti-psychotic.

About two weeks later, he yelled during an outburst at school that he "wanted to kill himself," according to information from the state Department of Children and Families. But he apparently showed no signs that he would really do so, and was not deemed suicidal following the tantrum. After another evaluation by his board-certified psychiatrist, Gabriel was kept on the drug regimen.

On April 14, a therapist noted that Gabriel "demonstrates no active psychotic features or suicidal/homicidal ideation or plan."

But two days later, Gabriel was dead. His apparent suicide -- hanging himself in the shower after another outburst at a "respite" foster home -- is still under investigation.

Drugs carried warnings

Given the frequent emotional dislocation in Gabriel's life, it is not known what role, if any, his prescriptions played in his apparent suicide. But Symbyax carries a warning that "antidepressants may increase suicidal thoughts or behaviors in some children... especially within the first few months of treatment or when changing the dose."

Vyvanse is approved for use in children 6 and over, but the manufacturer notes that the drug should not be taken by those in "agitated states." Aggression and abnormal behaviors are sometimes associated with its use.

These risks are among the reasons why Florida law requires informed parental consent or judicial order before administering psychiatric medications to foster children. Paperwork in Gabriel's case indicated consent had been given, but that was erroneous, DCF officials say. A statewide review of psychiatrically medicated foster children found consent documentation lacking in 16 percent of such cases -- a potentially serious gap in the safety net.

DCF seems to be treating its findings with genuine urgency, and is awaiting advice from a task force assigned to investigate other concerns, including medical, related to Gabriel's case. The added layer of review is important and sends an encouraging signal that the agency is sincere about improving its once dismal record.

But the dilemma over psychotropic medications for children will not be easily resolved.

These drugs are a godsend to many people, enabling them to escape the prison of profound mental disability. However, the potential risks, combined with the challenge of monitoring doses and the difficulty of distinguishing side effects, present a double-edged sword. In the case of foster children, for whom instability and frequent moves are common, the need for medical vigilance is paramount.

As Gabriel has sadly shown, a smile is not necessarily proof that the drugs -- or the system -- are working.