Once again, we're hearing that some of the most vulnerable among us -- foster children taken from their homes because of abuse or neglect -- are being treated with "powerful, mind-altering drugs."
The latest news comes from several different sources. Last week, ABC News aired the results of its damning year-long examination on the topic. Then, the Government Accountability Office, Congress' nonpartisan investigative arm, released a report showing that foster kids in several states are medicated at several times the rate of their peers on Medicaid.
The GAO report also found that, contrary to medical guidelines, foster children were more likely to be prescribed five or more drugs at once, be treated with dosages exceeding the recommended maximum, and to receive medications when they were younger than a year old.
A Senate subcommittee held a hearing examining the GAO report -- the latest of several congressional hearings in recent years involving foster kids and medication. Separately, prominent academic researchers released a study showing that, even compared to children who qualified for Medicaid because of a disability or low income, foster kids are far more likely to receive multiple psychiatric drugs at once.
The reaction to these reports has been overwhelmingly negative. This is hardly surprising. It's an easy subject to line up against. I mean, how many people are going to argue that we should be, as an outraged blog on the website of the Minot, North Dakota, paper put it, "drugging foster kids into a stupor"?
The reality, though, is far more complicated than it appears in the political theater of a congressional hearing, or in television news shots of sad-looking, adorable kids set to tug-at-your-heartstrings music.
The GAO report, which advocates that the U.S. Department of Health and Human Services do more to help states monitor and oversee the treatment of foster children, is sober and nuanced. Its specific findings regarding infants, treatment with five or more medications, and maximum exceeded dosages are alarming. But few people will read the report itself, and it's too easy to elide its specific recommendations into an argument against treating foster children, or just kids in general, with psychotropic drugs.
Knowing that, I'd like to share the experience of a former foster child whom I interviewed in depth for a book on growing up on psychiatric meds.
When I first heard this young man's story, he seemed to me like a perfect poster child demonstrating the horrors of medicating foster kids. But the more I heard, the more it seemed that although he had good reason to resent medications, his case was complex and far from clear-cut.
Like the children briefly featured in ABC News' recent investigation, this young man has fared so well without meds that at first glance you, too, might conclude he never should have been put on drugs in the first place. Now in his mid-20s, he hasn't taken medication since he secretly quit his anti-psychotic drug partway through high school. He's in college and also works several jobs, including mentoring foster children. He recently married the love of his life.
He spent most of his childhood and adolescence in foster care. For a decade he took medication for ADHD and then for bipolar disorder, conditions he's convinced he doesn't have. An antipsychotic drug for bipolar disorder seems to have caused weight gain and diabetes that disappeared when he stopped taking it.
But listening carefully to him over the course of many months, I came to think that perhaps medication was not the patently absurd and unjustified measure it had initially seemed.
He was taken from his disabled mother at age five because she was unable to keep him from roaming the streets of a neighborhood with warring gangs. His father beat him and his mother. And though this young man did not want to discuss it publicly, he hinted to having experienced further traumas, both with his parents and in the foster system.
After foster care officials permanently revoked his parents' custody, he bounced through at least two dozen placements, at one point spending months in an inpatient psychiatric facility. He thinks his rebellious behavior, which included beating up other children and vandalizing foster homes, was a factor in the frequent relocations.
He wasn't just a menace to kids around him. Adults who cared for him feared he might hurt himself. His actions included climbing up on to the roof of the group home where he lived and threatening to jump.
Although adults in his life maintained his psychiatric problems left him out of control, he insisted to me that he the acting out was a deliberate bid for attention. He felt so alone and neglected that any attention from adults -- even in the form of punishment -- was better than none. And he had grown up in a family and a community where being tough was valued and necessary for self-protection.
All he wanted, he told me again and again, was a loving family he could trust unconditionally. He says he fared much better when for a couple of years he lived with such a family. And when that couple adopted other children instead of him, he was devastated. He overdosed on his medication in an attempt to "fix" himself. Yet, the more he misbehaved, the more he hurt his chances for adoption.
So should a child like this be medicated? I think it's very difficult to say. The GAO report makes the astute but often overlooked point that, despite the alarming statistics about foster children being medicated at several times the rate of their peers on Medicaid, it's impossible to judge the appropriateness of their treatment without examining each child's file for information on diagnoses, dosages and the many circumstantial factors doctors take into account when prescribing. These are, after all, severely traumatized children who suffer from mental illness at disproportionately high rates. Being shifted from one placement to another only destabilizes them further.
I can understand why the young man I interviewed and several of the children in the ABC News investigation think they never should have been treated with drugs. Already neglected and abused by their parents, many of them felt adrift and alone in the foster system. Medication must have seemed like further neglect. Instead of relationships with adults who would listen to them and care about them, it seemed, they were given pills to shut them up.
Medication, in other words, came to represent just one more instance of the world not doing right by them.
But I can also understand why doctors, case workers, teachers and others might have thought meds useful in this young man's case. Though he says the particular drugs he took never did anything for him except cause unpleasant side effects, that doesn't automatically mean it was crazy for doctors to try a pharmaceutical intervention. He was, by his own account, a disturbed and disturbing kid.
The devil is in the details -- what doses he took of what drugs, for how long and for what diagnoses and contextual reasons. He did not want to give me access to the records that contained these details. Without knowing this information, though, I don't think it's fair to hold him up as an unambiguous example of the dangers of prescribing medication to foster children.
Yet that's usually what happens all the time in the debate over medicating foster kids. We hear alarming statistics that seem to suggest "overmedication" and hear brief personal anecdotes that seem to suggest the horrors of life in a medicated haze but provide little or no contextual information.
I spent many, many hours interviewing this young man, but all I can say is that he was dealt a very bad hand, that he didn't receive the love and stability that children need to flourish. Medications were a band-aid on a gaping wound -- fundamentally inadequate, but not necessarily unjustified.
Journalist Judith Warner, in a recent column in Time, suggests that too often, when it comes to psychological care for foster children, band-aids are all we're willing to pay for. It's worth noting that this particular young man received a battery of supports -- case workers, psychologists, specialized schools, "therapeutic" foster placements and yes, medication. These supports simply don't seem to have been coordinated in a way that motivated him to improve his behavior, and, most importantly, allowed him to heal.
He badly wanted a family, but loving and willing adoptive families, especially for the most difficult children, are understandably in short supply.
It's easy to declare in the abstract that "too many" foster children are medicated. What, though, would be the right number? When you get into the nitty gritty of individual kids' experiences, you see how difficult it is to make a call about what should -- and, realistically, what could -- have been done.
Follow Kaitlin Bell Barnett on Twitter: www.twitter.com/kbellbarnett
Jeanne Ball: ADHD Drug Shortage: Can Meditation Fill the Gap?
You can't read about the horrible childhoods without coming back to that old truth: Love is the Best Medicine. Ultimately, the only solution is to have fewer and better foster parents, and to make sure that any parent who is capable of caring for their children has plenty of support.
Lovely insight and bold statement, thank you Kaitlin.
How about the reverse? That bouncing him around like an out-of-control ping-pong ball was responsible for his acting out? It works both ways. I am not opposed to the use of medications for ADHD, which my son was on for some years, but I think they are often prescribed irresponsibly. I seriously question the use of anti-psychotics in kids, particularly that relatively new witch's brew called Abilify. Fixing the foster care system would go a long way toward fixing some of the kids' problems, but that would cost MONEY......and kids don't vote.
As a matter of fact I *did* read the GAO report, and yes, I saw the boilerplate about maybe it’s because foster children may have more mental health problems - some of them caused by being moved from foster home to foster home. But several factors suggest all those drugs are *not* needed. Among them:
--While all of the studied states use these meds on a shocking proportion of foster children, some are a lot more shocking than others. The range is from 19.7 percent in Oregon to 39.1 percent in Massachusetts. It is unlikely that Massachusetts foster children are twice as likely to have problems requiring medication as Oregon foster children.
--But the “smoking gun” on these issues comes from some findings in Florida and Oregon that are not in the study. Officials in both states found that when a child is placed with a grandmother or other relative he is dramatically less likely to wind up on meds than when that child is placed in an institution, a group home, or even a foster home with a stranger.
Richard Wexler
Executive Director
National Coalition for Child Protection Reform
www.nccpr.org
I have seen no studies showing that children placed with relatives are less troubled than children placed with strangers. In theory when the child is taken, the CPS agency always is supposed to first look for relatives. Yet the variation among states is enormous, ranging from only five percent of children placed with relatives here in Virginia to 44 percent in Hawaii. It's highly unlikely that Hawaiian children are more than eight times less difficult than Virginia children. Whether a child is placed with a relative is likely to depend less on whether one is available or the problems of the child than the general attitude toward relatives among caseworkers in that state.
As with almost everything else in child welfare, the decisions on where children are placed tend to be arbitrary, capricious and cruel.
And we're not talking about a small difference here. The most recent monthly report from Florida showed 23 percent of children in foster homes with strangers were on psychiatric medication, compared with only five percent on foster homes with relatives. According to a recent news story, there is a similarly large difference in Oregon.
By the way, you might be surprised, and depressed, to find out how many advocacy groups quote studies they *don't* read. Here's a case in point, much in the news right now:http://t.co/AcO2JaLA
Richard Wexler
Executive Director
National Coalition for Child Protection Reform
www.nccpr.org
So I say keep it simple - if you want to try psychiatric drugs, try one. If the kid doesn't get better, take him off and try something else. It's not really that hard to do - unfortunately, we are so enamored of the drugs that we don't seem to notice when they don't actually work.
Very true - evidently the medications he was on did not work for him. But it doesn't mean that no medication would have worked, or that the doses he was on were correct or appropriate, or that he wouldn't have been even worse off with no meds. Medication is one factor in a very complicated stew of influences that contribute to a child's wellbeing. To examine it in a vacuum, as people so often do, is misguided.
Children in treatment all too often grow up into adults in treatment. This is not about "sickness", except in so far as "sickness" is dependency. 1/2 of all LIFETIME cases of "serious mental illness" were 1st diagnosed as such by the age of 14 years old says one NIMH stat I believe. When you label foster kids and drug them, you could be starting them down a path that only ends with death, and I don't imagine that it is the best direction at all for them to take. I ask you, do we really need to write off MORE children as a loss to psychiatry in collusion with the foster care system than we have? I certainly hope not.