Caretakers Routinely Drug Foster Children
Children under state protection in California group and foster homes are being drugged with potent, dangerous psychiatric medications, at times just to keep them obedient and docile for their overburdened caretakers.
A review of hundreds of confidential court files and prescription records, observations at group homes as well as interviews with judges, attorneys, child welfare workers and doctors across the state, revealed that youngsters are being drugged in combinations and dosages that experts in psychiatric medication say are risky--and can cause irreversible harm.
In part because of a lack of oversight, officials responsible for the children’s welfare say they don’t know how many of the state’s 100,000 foster children are being given mood-altering medications, many of which have never been tested for use on children.
In Los Angeles County--which has nearly half the state’s foster children--dependency court judges last year approved requests to medicate about 4,500 kids. That doesn’t include those drugged with parental consent or those drugged with no consent at all, which experts believe is a significant problem. In addition, a county grand jury found in 1997 that nearly half the group home children it examined were drugged without court or parental consent.
Experts from around the state said widespread drugging, both with and without legal approval, occurs in other California counties as well.
“We sometimes don’t know who put kids on drugs and why,” said Nathan Nishimoto, an Orange County Department of Children and Family Services official who, until recently, was in charge of tracking children in the county’s care.
There’s the 5-year-old boy in a Tustin group home who was not only being given an antipsychotic, but massive doses of Ritalin and clonidine--though researchers from UCI and UCLA have published articles reporting that that combination has caused sudden death and heart problems in some children.
There’s the 8-year-old foster child in San Francisco County on Cylert for his hyperactivity, despite warnings from the drug’s manufacturer that its use can lead to liver failure and death in children. The boy did not receive the requisite blood checks to monitor the drug in his system.
At the Orangewood Children’s Home in Orange County, kids as young as 3 skip up to the drug cart several times a day, to take the “meds” that control their “depression” and “rage.” To say nothing of the scores of California teenagers prescribed pills to battle manias and psychoses with little explanation of why or by whom.
Many psychiatrists vigorously defend the use of psychotropic medications on children in foster homes and group homes, arguing that the benefits of using them on these often troubled youths outweigh future risks of harm. “Your hand gets forced when these children are so disruptive,” said professor Stephen M. Stahl, who teaches psychopharmacology at UC San Diego. “How sick would they be if you didn’t give them drugs?” he asked.
Dr. James Hogrebe, who works with grade-school-age children at an Anaheim group home, said, “Most [of these medications] can be used safely, if they’re monitored correctly.”
But the lack of proper monitoring is precisely part of the problem, say numerous officials involved in the child welfare system.
Prescription Records Scant or Nonexistent
Many child psychiatrists, attorneys and children’s advocates say the apparently widespread practice of drugging amounts to a form of medical experimentation on some of the state’s most vulnerable kids--those taken from parents who abused them.
In many instances, the doctors who prescribe what their colleagues call “chemical straitjackets” aren’t psychiatrists and have little training in the highly specialized field of psychiatric medications.
According to group home directors and child care workers, some of these doctors and psychiatrists examine a child for minutes before prescribing powerful, behavior-altering medications. And some come after dark, when children are asleep, look at files and write prescriptions.
These revelations come at a time when many experts have expressed serious reservations about the rising number of kids in the general population who are being prescribed adult medications.
An estimated 800,000 children and adolescents nationwide last year were prescribed antidepressants such as Prozac, Paxil and Zoloft, according to IMS America, an industry research firm that surveys physicians. Another half a million children, aged 6 to 12, were prescribed Tegretol and Depakote, two adult antimanic, antiseizure drugs, the firm’s data shows. And in 1996 some 3.25 million in that age group were prescribed drugs such as Ritalin to control hyperactivity, IMS America says. Controversy or no, such drug use by kids in the general population is at least monitored by parents and physicians.
But psychiatrists in several California counties say sometimes the only way they know what drugs a child in a foster home or group home has been taking is if the child can remember such obscure names as Desyrel (an antidepressant), Mellaril (antipsychotic), Tegretol (antimanic) or Catapres (antihyperactivity).
One Orange County teenager filled a notebook page with the cornucopia of drugs she’d been given; few of the drugs had been logged in her official files.
An 8-year-old state law requires that foster children’s medical histories be recorded in “medical passports” and follow them from home to home. But this requirement is routinely ignored as too burdensome, officials say, and children’s medical records are often incomplete. For most kids, every time they move, their care passes to different physicians and psychiatrists.
“When I get a new kid, I have no idea what [medications] he’s been on,” said Dr. Kenneth Steinhoff, UC Irvine’s chief of child psychiatry, who also sees children in a group home. “I don’t know who the [child’s previous] doctors are. You get practically nothing. It’s a crime.”
In San Bernardino County, Jeff Broyde, head of the public defender unit representing children, said it’s difficult for his office to monitor whether a child is getting proper treatment; each attorney in his office represents some 1,200 children who sometimes are housed hundreds of miles away.
“There’s no way we can run out there and see . . . if the child is OK,” he said. “The important thing [is] seeing the child. If you see a child looking like a zombie, it’s wrong, even if it’s medically permitted.”
In numerous interviews across the state, one official after another--from individual foster parents to judges to doctors--described occasions where children seemed to be misdiagnosed, given the wrong medication or given too much medication.
* In Los Angeles County, judges who oversee the cases of foster children have become so concerned by the widespread disbursement of drugs that in April they imposed a system designed to ensure that a child had been thoroughly examined and that other options had been tried before psychiatric drugs were prescribed. Each psychiatric diagnosis and prescription must be reviewed by county psychiatrists before court approval.
“We all have enormous fears that our decisions, one way or another, are going to cause serious harm to these children,” said Terry Friedman, presiding judge of the L.A. County dependency courts. “This, more than any other decision as a judge, causes me enormous anxiety.”
Drugging Without Consent Widespread
One of the new policy’s architects doubts it will provide a complete answer to the problem. A report by the Los Angeles County Grand Jury in 1997 suggested that his concerns are valid: An audit of 158 cases found that children in group homes were being drugged without the legally required consent nearly half the time.
Dr. Michael Malkin, chief of mental health services for the county’s juvenile courts, said there is no real punishment for doctors who don’t seek court approval, and reviewing the consent forms that are submitted doesn’t answer the basic questions: Does the child truly need the medication, and do a drug’s benefits outweigh its sometimes serious side effects?
John Tobin, the county’s mental health coordinator, said the sheer number of doctors treating children in Los Angeles makes quality control nearly impossible. Last year, more than 400 doctors requested court permission to drug nearly 4,500 children--more than 300 under the age of 6. And these numbers don’t include the many children whose parents consented to the medication, precluding the need for court approval. Nor do they account for the number of foster and group home kids, such as those the grand jury found, who had been drugged without anyone’s consent.
* In San Diego County, Juvenile Court Referee Michael Imhoff says legislative intervention might be the only way to control the use and misuse of psychiatric medications. “I think everyone will agree that the scope of this problem is expanding,” Imhoff said. “It’s a systemic problem.”
Imhoff said the court’s supervising judge now reviews every request to medicate a child, and San Diego’s dependency court judges are “absolutely frightened” that children are being drugged without their knowledge. Sooner or later, he said some calamity will occur “that will be very difficult to explain.”
Some Homes Seem to Sedate All Toddlers
Ana Espana, who supervises the unit in the county public defender’s office that represents foster children, said she has personally encountered cases of foster children being drugged improperly.
“We had a 5-year-old client who was kept in a psychiatric hospital for over a month, who had multiple changes of medication, and we didn’t find out for weeks after,” said Espana. “Our feeling was this child was being experimented on. We got him out and into another facility, and they [the doctors at the second hospital] were horrified by what he’d been on.”
She said she had been to foster homes where all the toddlers appeared to be sedated, and her office would later find out the children were drugged without anyone’s permission.
* In the Bay Area, several psychiatrists who treat foster children say they regularly see children who have been put on multiple medications by a variety of doctors. Dr. Lynn Ponton, a professor of adolescent psychiatry at UC San Francisco, said a 14-year-old girl who had been living in a group home recently showed up for an appointment on antipsychotics and antidepressants. “She’d been on these medications for a year and nobody knew why she was on them or who put her on them,” Ponton said. “They dump [kids] on these meds instead of worrying about continuity of care and therapy.”
* In Orange County, controversy over the questionable use of psychiatric drugs on foster children has surfaced before. More than three years ago, the county hired a UCLA professor, a Torrance psychiatrist and a pharmacologist from a state hospital to investigate complaints by one of its own managers that children at the county’s temporary shelter, Orangewood Children’s Home, were being improperly medicated.
The report has never been made public, but the county’s Juvenile Justice Commission last summer released a brief summary of the major findings, accusing some Orangewood psychiatrists of jeopardizing the health and well-being of children in their care by deviating from “normal, customary practices” in prescribing psychiatric drugs.
Daun Martin, a psychologist and former chairwoman of the Juvenile Justice Commission, said she was “shocked” at the practices at the shelter. “It was apparent from the consultants and the records that there were some serious health risks to children,” Martin said.
Tim Mullins, until recently the county’s director of mental health services, said the problems at Orangewood have been corrected.
But according to several child psychiatrists, who reviewed approved medication consent forms for children staying at Orangewood, problems persist. The medications requested on some consent forms didn’t correspond to the diagnoses, the psychiatrists said, and the amount and combinations of drugs in some cases were “outrageous.”
In one case, a county psychiatrist put an 11-year-old girl on large amounts of Tegretol, Depakote and Clonidine for attention deficit and hyperactivity disorder and “aggression/agitation.” Dr. Thomas Hicklin, head of the child psychiatry ward at the Los Angeles County-USC Medical Center, said either the diagnosis or the medication had to be wrong. “That’s appropriate treatment for mania and bipolar disorder. You wouldn’t treat ADHD with those drugs,” Hicklin said.
In another case, an Orangewood psychiatrist asked to put a 15-year-old boy on massive doses of the antipsychotic Risperdol “indefinitely,” and the antidepressant, Trazodone, for behavior outbursts, impulse control and insomnia. “There would be no justification in the literature for such treatment,” said Dr. James McGough, an assistant professor of child psychiatry at UCLA, who reviewed the boy’s medications. The psychiatrist “is putting this child on medication for a grown man with full-blown schizophrenia. In my mind, it borders on criminal.”
Dr. George Pascarzi, the county child psychiatrist who reviews all the medications prescribed at Orangewood, says “those two cases would certainly be considered unusual,” though he is comfortable with the medication in both situations. He said he would need to know more about the 11-year-old girl’s medical background to judge whether the combination and doses of the drugs were correct, whether other medications had been tried first and what levels of the drugs were detected in her blood tests.
Pascarzi says that at least while the children are at Orangewood, they are given complete medical evaluations and, if necessary, monitored with EKGs and blood tests to make sure the medications are not harming them.
There’s no question that the use of adult-strength medications to relieve depression, and to control manias, psychoses and rage, were at one time well-intended and a valid means to help the system’s most severely disturbed children. But as the number of kids in the child welfare system has exploded over the last decade, so too has the use of powerful, controlling medications on children, some of whom may not need them, experts say.
Joe Huley, in charge of group home inspections for the Orange County Department of Children and Family Services, ordered one Tustin group home for children ages 3 to 12 to fire its psychiatrist in 1996, after discovering that the doctor was prescribing the tranquilizer Thorazine for every child in the home--whether they needed the medication or not.
Prescribed for Need or for Convenience?
Many parents say they believed their kids didn’t require medication but felt pressured to sign consent forms because they hoped to regain custody of their children and didn’t want to appear uncooperative.
“What can I say about it? If I protest, they’ll say I don’t care about the kids,” said Janet Van Eyk of Orange, whose three grandchildren were taken from her after she was accused of abusing one of them. “I had the girls assessed at school for hyperactivity and they said they didn’t need drugs. Now they have them on them.”
While many kids do need treatment, many others in the state’s care are drugged for expressing normal angry reactions to abuse and abandonment--or for just being rambunctious kids, say children’s attorneys and some psychiatrists.
Psychiatrists, or sometimes simply internists, employed by some group homes respond to the complaints of harried child-care workers by prescribing medications or increasing dosages on the basis of a phone call from an untrained worker, say child advocates and the workers themselves.
“Putting kids on medication is easier for the people who care for them,” said Dr. Euthymia Hibbs, chief of psychosocial treatment research for children and adolescents at the National Institutes of Health. “It is more convenient for everyone around--but the kids.”
J. Michael Hughes, an Orange attorney who represents children in protective custody, agreed, “The group home calls up and says, ‘Johnny is acting up.’ So they give him a drug. It’s perennially a problem in these group homes.”
Dr. David Chadwick, director emeritus for the Center for Child Protection at the Children’s Hospital of San Diego, said doctors and court officials there became concerned when it appeared that foster parents were having unruly children put on medication without proper examinations or consent. In two separate instances, Chadwick said, foster children ages 4 and 5 came in for medical exams taking antipsychotics and antihyperactivity drugs. “The foster mothers had relations with certain doctors where they could just call up and get meds,” Chadwick said. “There was not what I considered a sufficient evaluation before they prescribed the drugs.”
Professor Stahl from UC San Diego places part of the blame on a child welfare system that cheats doctors of the resources they need to do their jobs. “The doctors don’t have time to make an assessment. The fastest thing is to use chemical straitjackets on the kids--and some of them probably need it.
“You’re forced to use drugs because [the group homes] are understaffed and they’re unnatural environments,” Stahl added. “The facilities have to be safe.”
Usually there are three or more traumatized kids for every group home staffer, though there can be as many as eight. The workers, typically fresh out of college, are paid $7 to $9 an hour and seldom stay longer than a few months. Drugging kids is cost-effective: Most pills cost from 3 to 17 cents. Therapy is an expensive proposition.
“A lot of these kids suffer from a deficit in attention, not attention deficit disorder,” said James Swanson, a psychologist who heads UCI’s Child Development Center.
“If we were to get more one-on-one with these kids over a longer period of time,” said Javier Chavez, a senior counselor at Orange County’s children’s shelter, “they wouldn’t need all those meds.”
It is resoundingly unclear how “all those meds” may be altering children’s lives. Anecdotally, however, experts say there are numerous disturbing accounts.
Under the influence of such drugs, children have suffered from drug-induced psychoses, hallucinations, abnormal heart activity, uncontrollable tremors, liver problems and loss of bowel control, according to health professionals, attorneys and court records.
The manufacturers of some drugs, such as the antidepressant desipramine, specifically warned doctors not to give the drug to kids after some children became ill or died as a consequence of taking the drug. “We advise against using [desipramine] in children,” said Charles Rouse, U.S. director of communications for Hoechst Marion Rousell, the maker of the antidepressant.
Because the drugs have been approved by the U.S. Food and Drug Administration for adults, a doctor can prescribe them to patients of any age, even though they have not been tested on children.
“These drugs can result in a toxic reaction, either something that makes the child really sick or . . . makes the kid dead,” said Dr. Chadwick from the Center for Child Protection in San Diego. Chadwick was hired as a consultant in a court case involving a Seattle foster child who died in 1996 after being given toxic doses of an antihyperactivity drug.
No foster children in California are known to have died from excessive or improper medications. But child advocates say prescription drugs could have played a role in some cases where death was blamed on unexplained heart arrhythmia or other organ failures.
One such death occurred in March in San Bernardino, where a 10-year-old boy in a group home was found to have died of a heart attack brought on by unknown factors. A police detective said toxicological tests showed that the medications in his system were within acceptable limits, so the death may never be explained.
Beyond the physical side effects, experts worry about how or if these medications affect children’s ability to have normal relationships, to learn, and to have and rear children of their own.
Children between the ages of 3 and 6 who take antipsychotics such as Mellaril and Haldol have been found to have learning problems. “Your brain is wired to learn things during that period that you can’t learn later,” Dr. McGough from UCLA said. “There’s a real risk. Nobody knows the long-term effect.”
Some doctors and child advocates worry that the pills set the children, often the progeny of drug abusers, on a lifetime of drug dependency.
“This is the wrong message to send to children: ‘Take this pill and you’ll feel better,’ ” said Dr. Thomas Laughren, medical reviewer for the FDA’s division of neuro-pharmacological drugs.
Added McGough: “You’re really teaching them that they’re dependents and damaged and need drugs to be normal.”
Some psychiatrists may be unaware of the serious side effects that some of these drugs can have, because they spend so little time with the children--unlike their caretakers.
At a Tustin group home, one 3-year-old boy appeared so dazed and incommunicative that a therapist said he would never leave the child welfare system or his medications, that he was retarded and unadoptable. But when Greta Anderson, a Costa Mesa foster parent, took in the 30-pound boy she learned he was being given large doses of clonidine, a drug used to fight both depression and hyperactivity, three times a day.
“The amount of medication he was on for a 3-year-old was just incredible,” Anderson said. “Once we got him off the drugs, his vocabulary increased tenfold, he was potty-trained and his medical diagnosis went from mental retardation to learning disabled.”
“I’m not against medications,” said Anderson, who is in the process of adopting the boy. “I’m against sedating children.”
Dr. Malkin also sees the effects of over-drugging. He recounted the case of a 9-year-old girl in Los Angeles County who ended up back at the county children’s shelter after attacking her foster sister with a knife. The girl’s Ritalin prescription had been upped to dosages far beyond those recommended for her age and weight, Malkin said.
“She was psychotic when she got [to the shelter,]” Malkin said. “She just had a toxic amount of Ritalin in her system. When we took her off the medication, she was fine.
“The only real solution,” Malkin said, “is to have social workers with caseloads of 10 kids. The thing that’s missing is to have someone in the parental role. Someone who shares the child’s destiny.”
* DAILY PILL ROUTINE: Steven and Kenny’s ritual is repeated across California. A31