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Why are so many foster kids taking psychiatric drugs?
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Foster kids face significant challenges, and better data, oversight and therapy may be needed. . - photo by Eric Schulzke
Californias Legislature is poised to pass a law making it much harder to offer psychiatric medication to kids in foster care, responding to growing concern that foster kids get too many psychotropic medications.

Last month the California Senate responded to the problem with a package of four bills focused on tighter judicial oversight, better medical monitoring and better medical protocols for the use of the drugs in group home settings.

At a glance, the numbers do seem troubling.

Nearly one in four adolescents in foster care are on psychotropic drugs, a California State Senate Committee on Human Services reported earlier this year, with 56 percent of those in foster care on the meds.

More concerning, the California Senate committee noted, 60 percent of those on the medication were receiving anti-psychotic drugs, which are reserved for very serious conditions and often have serious side effects, and 36 percent of the adolescents had multiple prescriptions, which often lead to complications.

Given with poor oversight and little attendant therapy, critics say, those potent drugs in unpredictable blends are asking for trouble.

"We have a major problem," said Julie M. Zito, a professor of pharmacy and psychiatry at the University of Maryland, "and California has done us a great service in calling attention to this vulnerable population."

But some experts fear that the rush to judgment will not serve kids in the long run. "The issue is more complicated than many of the one dimensional articles presented in the press would suggest," said Michael Naylor, director of the Division of Child and Adolescent Psychiatry at the University of Illinois at Chicago.

Better protocols

There seems to be little disagreement we do need better data and better protocols to make sure that drugs are accompanied with proper personal therapy and that dangers are seen early.

"There are states where if you go into a child's file you would be shocked to see the disarray," said Sarah Bartosz, lead counsel for Children's Rights, a New York City-based advocacy group.

Most states keep poor records on the medical history of foster children, Zito said, and as a result cannot really know how many medications they are taking or how they are playing out. "The history of the child becomes atomized and fragmented," Zito said. "Informed consent breaks down, drugs stack up on top of each other, medical records are often not updated and red flags are missed.

"You can't just be looking through this lens of I'm giving pills and doing good," Zito said. A particular problem comes when children are given multiple medications when the interactions, safety and dosing of the blends are poorly understood.

Without parents invested in their care, foster kids are especially vulnerable to cursory doctor visits. Proper procedure, Zito said, requires that a doctor carefully consider progress, meeting with a child often and for longer sessions. What can you get out of a 15-minute session? she asked.

Zito says the problem extends beyond foster care to concerns about over-medicating children in the U.S. for mental health and behavioral problems.

We over-medicate the poor, especially the most vulnerable, including foster care, she said. We have good clinical guidelines in child psychology and pediatrics, and yet when we look at population-based analysis we come away with enormous disparities between the various subgroups.

Oversight in Illinois

Naylor works with the state child welfare agency in Illinois, a state he sees as fairly advanced in its oversight procedures. Illinois has an agency known as the Office of the Guardian that is required to give consent for major medical decisions for foster children, including psychiatric care.

The Office of the Guardian, in turn, must consult with the system's psychiatric consultant, which is the role Naylor himself currently plays. Doctors have to fill out a detailed form before a prescription is approved. That information is entered into a database, which allows Naylor and his colleagues to look at the child's whole medical history and profile.

"We will often deny the medication if it does not look appropriate," Naylor said. "We used to deny as many as 10 percent. Now we are denying fewer, partly because they better understand how we make the decisions."

For one thing, he said, doctors now understand that issuing multiple drugs at once to a child will result in a quick veto.

Naylor cautions against facile comparison between states. For one thing, he said, much hinges on how many kids are brought into foster care in the first place. Illinois is very selective, Naylor said, bringing 50 percent fewer kids into the system than the U.S. as a whole. By definition, he said, these kids will have more problems, and thus require more medication.

Chemical soup

Naylor argues that many kids in foster care have psychiatric problems that began well before birth, so it should be no surprise that a disproportionate number of them end up medicated.

These are kids with all of the risk factors for major mental illness, Naylor said. Foster kids usually come from homes where birth parents had major mental issues, and even in utero, he argues, they are often swimming in a chemical soup of alcohol, drugs and the stress hormone, cortisol, which set them up for challenges as they develop.

Cortisol is almost universally overlooked, Naylor said. Most kids born into stressful environments resulting in foster care had parents who were economically and socially stressed. A mother under severe stress will immerse her unborn child in stress hormones, he said, with troubling effects down the road.

In Illinois, our goal is not to increase the use of the drugs, Naylor said. Its not to decrease their use. Its to figure out when it becomes appropriate to use them, and what the appropriate dosages would be.

Here, even harsh critics of the status quo seem to agree.

"The social need is undoubtedly there," Zito said of foster kids. "I'm not suggesting these are not needy children." What Zito objects to, she said, is the heavy emphasis on medication as the solution to these problems.

We dont want 'psychotropic' to become a dirty word, Bartosz said. "Our objective is better oversight, not to eliminate the use of drugs for this population. For some kids, medication is appropriate and beneficial."