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December 9, 2007

Potent Pills: More foster kids
getting mood-altering drugs

When Laticia Anderson's son entered foster care in 2005, a social worker described the 4-year-old as "an extremely smart little boy who loves school."

But over the next six months, as he was shuttled from an emergency foster-care placement to two foster homes, his personality changed.

The boy would explode in tantrums, gouge his own flesh, even consider killing himself. Social workers and pediatricians could not quell his outbursts.

Frustrated, they resorted to Depakote, an anti-seizure medication intended for adults but occasionally given to children to alter their moods.

And then her son's personality really changed, Anderson said. The boy she knew as playful and exuberant was, when she visited him, distant and withdrawn - "almost like a zombie."

Like Anderson's child, hundreds of foster children in Monroe County each year are placed on psychotropic, or mood-altering, drugs. Though questioned in some medical and psychiatric quarters because of long-term health risks, the use of the psychotropic medications on foster care children in Monroe County is on the rise, a Democrat and Chronicle investigation shows.

The investigation included analyzing data from county, state and federal agencies; interviewing experts locally and nationwide; interviewing families of some local foster children on medications; and reviewing public records of Monroe County Family Court cases in which the prescription of the drugs has been an issue.

The investigation reveals that:

  • In 2002, about a third of the county's foster care population, 327 children, were prescribed one or more common psychotropic drugs. By the end of 2006, the number had increased about 40 percent to 457 foster children, or almost half of the county foster care population.
  • In the five years from 2002 through 2006, according to state data, Medicaid expenditures for common psychotropic medications for Monroe County foster children nearly doubled - an increase almost four times the statewide rate.
  • Psychotropic medications are also more commonly used at residential foster care treatment centers than in the past, according to medical and psychiatric staff. At the nonprofit Hillside Children's Center, for instance, 55 percent of the foster children are prescribed one or more psychotropic drugs.
  • 2006 records show that more than one of every eight foster children in Monroe County is on some kind of drug to combat psychosis, a severe form of mental illness characterized by lost contact with reality.
  • Very young children are also prescribed the psychotropic medications, according to county data.

    Last year, a 1-year-old foster child was prescribed the antipsychotic drug Risperdal, and two 4-year-old foster children were prescribed Depakote. Pediatricians say Risperdal and Depakote, if properly monitored, can be safely prescribed for young children, but some medical experts worry about possible health effects. Risperdal has been associated with heart disease in older adults; Depakote has been linked to liver failure in children younger than 2.

    Drugs a straitjacket?

    Foster care advocates say children are a particularly vulnerable population, often invisible to the public and beset with higher rates of mental and emotional illness in large part because of the disruptive - and sometimes abusive - lives they've led.

    This leads to a conundrum: Are foster children legitimately prescribed psychotropic drugs more commonly because they have so many needs? Or are the drugs used more as a convenient way to straitjacket troublesome behavior?

    The use of such drugs "definitely has gone up, and I say that with much reluctance because I don't think these medications are necessarily safe medications," said Dr. Mohsen Emami, a staff psychiatrist at St. Joseph's Villa in Greece, a nonprofit residential facility for troubled youths.

    Across the country, while the use of psychotropic medications for all children has increased, the rate of use for those in foster care has grown even faster. By some estimates, foster children receive psychotropic drugs at a rate two to three times that of other children.

    "I have no doubt that many, many kids are overmedicated," said Dr. Martin Irwin, a Syracuse-area psychiatrist who has been contracted by counties and treatment centers around the state to help decrease the use of psychotropic drugs for foster children.

    "It's out of control in general, but the worst problems are in foster care because there's basically nobody advocating for the kid."

    Keeping tabs on drugs

    Local psychiatrists and pediatricians who work with foster children say that although they worry about increased use of the medications, they can ward off bad health effects by keeping close tabs on reactions to the drugs. Many of the drugs require frequent monitoring of blood levels, lipid counts or liver function, depending on the particular side effects.

    "We're always being as careful as we can because we want to know we're doing it safely," said Dr. Stuart Loeb, a child psychiatrist who is medical director at Hillside Children's Center.

    Monroe County operates a nationally recognized clinic, called Starlight Pediatrics, for foster care children in home settings.

    The clinic centralizes care for foster children to ensure they receive preventive and other necessary medical treatment.

    Still, the clinic and Monroe County Department of Human Services, which manages foster care, have not been without controversy on the issue of psychotropic medications.

    Last year, Monroe County Family Court Judge Marilyn O'Connor rebuked the clinic and county social service workers in two separate cases for what she declared to be the questionable prescription of drugs to foster children.

    Both cases involved the prescription of Depakote - in one case to Laticia Anderson's 4-year-old son and in the other to a 2-year-old girl.

    While both cases centered on whether the county received proper consent from a biological parent to prescribe drugs - parental consent is typically required for such a prescription - O'Connor in one ruling challenged whether the medication was even warranted and if the risk of side effects was sufficiently considered.

    O'Connor ruled that "the decision to medicate this child was based on hearsay, limited information and without any complete evaluation of an existing mental health issue by a psychiatrist or psychologist," a contention the county has denied.

    O'Connor, who will retire from the bench at the end of this year, said she grew concerned because of the number of foster children she sees in court on psychotropic medications.

    While refusing to discuss specific cases, she said in an e-mail: "Anecdotally, many of the children who appear before me ... are on some form of medication and I believe it is higher than what is being prescribed to the general population of children. Other factors affect this, but I am alarmed by what I see in the reports I receive."

    Laticia Anderson was also alarmed when she visited her son after he was put on Depakote. "He was real tired. He didn't act like a kid any more. He didn't have that play in him. He didn't have that 'go' in him."

    Anderson no longer wanted him on the medication. She challenged whether she had given true consent. County attorneys argued at a hearing that the drugs were prescribed "in his best interest," but O'Connor ordered the medication halted unless Anderson consented.

    Now 6 years old, the boy is in a compatible, loving foster home, said Anderson, who has three other children in foster care.

    And he is no longer on Depakote. "Now he's a normal kid. He laughs. He plays. He can tell you what he thinks. He couldn't do that on the meds."

    Children 'more disturbed'

    There are about 800 children now in foster care in Monroe County, counting those in individual homes and in residential treatment centers such as Hillside and St. Joseph's Villa.

    Many have been removed from the homes of drug-addicted parents. Many have been severely abused. Many don't know the benefits of a healthy diet or even the pleasure of a good meal.

    The transition to foster care can add to their trauma.

    "They're in a neglectful, intellectually and emotionally impoverished or abusive environment" at their parental home, said Dr. Michael Naylor, a Chicago child psychiatrist who is an expert on the use of psychotropic drugs for foster care children.

    "Then it just gets worse. These kids are taken out of their home and there's a disruption of parental attachment. These kids are attached to their parents, even though they are not often particularly very good parents."

    About 45 percent of the school-age children seen at Starlight Pediatrics are in special education programs, half of them for behavioral or emotional problems, said the clinic's pediatric director, Dr. Moira Szilagyi. Three of every 10 children using the clinic suffer from some form of chronic illness, ranging from asthma to seizures.

    Szilagyi, a Mendon resident who is nationally recognized for her work with foster care children, said the clinic does not resort to psychotropic drugs without being convinced that other options, such as therapy and counseling, won't work alone.

    Typically, the clinic won't prescribe psychotropic medications without consulting with mental health professionals, she said.

    The clinic often works closely with the University of Rochester's Mount Hope Family Center to determine the best answer for a child's needs, she said. "We work very hard at getting them into services."

    Still, medication may be necessary and beneficial when paired with therapy, she said.

    Although state and local data show that Monroe County's use of psychotropic drugs for foster children has increased, the reason behind that increase is less clear. Szilagyi said that foster children in Monroe County have greater access to services, and that higher uses of medication may be evidence that the children are being diagnosed better than in other communities.

    In Onondaga County, for instance, the use of common psychotropic drugs in the foster care population is even greater than in Monroe County, according to state data. Onondaga is known as a county that tries to rigorously evaluate the needs of foster children, Szilagyi and other experts said.

    The use of psychotropic drugs at foster care residential programs has likely increased because the county is trying to route only the most demanding children there, said Cindy Lewis, director of the Child and Family Services Division of the county's Department of Human Services.

    Officials at those programs agree that the needs of their children are even more dire than in the past. "I think in all of our services, we see children who are more disturbed and more dysfunctional," Loeb said.

    About a third of the children at St. Joseph's Villa are on psychotropic drugs, Emami said, and many of them had been prescribed drugs before entering the program. "I would say at least a third of them arrive on two or three psychotropic medications. Some of them are so fragile that if you try to lower the dose, they really struggle."

    Similarly, many children already have prescriptions for psychotropic drugs before they arrive at the foster care clinic, Szilagyi said.

    Deciding if and when to prescribe psychotropic drugs often tears at him, Emami said. "These medications have benefits - I certainly have seen it in 30 years of practice. But they also have serious side effects."

    Over-prescribing?

    The growing use of psychotropic drugs is not a trend unique to the foster care community. The prescription for all children has significantly increased in the past 15 years.

    Between 1994 and 2001, the prescription of psychotropic drugs for teenagers increased by 3 1/2 times, with much of that gain coming after 1999, according to a Brandeis University study. Other studies show that pattern has continued.

    "The Holy Grail here is we want to know what's appropriate (for prescription) and what's not," said Cindy Parks Thomas, a Brandeis University professor and expert on prescription drug trends who worked on the study.

    "When you have a high growth in prescribing, it can mean things are being overprescribed. On the other hand, it can mean we are identifying things that need to be treated," Thomas said.

    The prescription of Ritalin and other attention deficit disorder medication has exploded in the past three decades, and in the 1980s, the prescription of antidepressants for children became more common. Antipsychotic drugs are now also given to children and teens.

    Irwin and other child psychiatrists worry that their colleagues are too quick to pin a "disorder" label on a child and turn to drugs when intensive counseling and therapy would be a safer, more effective approach. Many have challenged the recent surge in the diagnoses of adolescent bipolar disorders, for which Depakote is often prescribed.

    A recent study funded in part by the National Institutes of Health determined that the number of doctor visits resulting in a diagnosis of bipolar disorder of a child or adolescent increased by 40 times over the past decade.

    The increased use of psychotropic drugs among foster children has greatly outstripped the rate within the overall population, many studies show. This isn't surprising to those who work with foster children, given their needs.

    "When you look at these youngsters, one can hardly imagine a group of children or adolescents that have more stacked against them," Naylor said. "Mental health issues. Abuse. Neglect."

    But some psychiatrists say that many in the field too routinely use drugs as a remedy.

    Irwin said: "Most medication for foster kids is given because they have behavior that adults don't like."

    GCRAIG@DemocratandChronicle.com



  • Common psychotropic medications:
    Ritalin, Concerta (Generic: methylphenidate): Nervous system stimulants, used often in response to attention deficit disorder and hyperactivity.
    Abilify (aripiprazole): Antipsychotic medication often used for bipolar disorder or other mood disorders.
    Risperdal (risperidone): Antipsychotic medication also used for mood disorders and also sometimes for treatment of autism.
    Seroquel (quetiapine): Antipsychotic medication also used for mood disorders.
    Zyprexa (olanzapine): Antipsychotic medication also used for mood disorders.
    Zoloft (sertraline): Antidepressant medication.
    Topamax (topiramate): Antiseizure medication sometimes used to help stabilize weight.
    Depakote (divalproex sodium): Antiseizure medication now sometimes used for mood disorders.
    Lexapro: (escitalopram): Antidepressant medication.



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