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?

"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

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'

"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?

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