updated 3/13/2007 4:43:25 PM ET 2007-03-13T20:43:25

Coast to coast, states are wrestling with how best to treat the legions of emotionally troubled foster children in their care. Critics contend that powerful psychiatric drugs are overused and say poor record-keeping masks the scope of the problem.

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Nationwide, there are more than 500,000 children in foster care at any one time, and more than half have mental illness or serious behavioral problems, according to the Child Welfare League of America.

“The child welfare system wasn’t prepared for the deluge of kids that have mental health problems,” said Dr. Chris Bellonci, a child psychiatrist in Needham, Mass. “By default, it’s become a mental health delivery system, and it’s ill-equipped to do that.”

Some states have taken broad action — often in response to overdose tragedies, lawsuits or damning investigations. California requires court review of any psychotropic drug prescription for a foster child; Illinois has designated a prominent child psychiatrist to oversee such reviews.

In other states, however, experts say the issue is not being adequately addressed and basic data is lacking that would show the extent of medication usage.

“It’s a problem that’s really ugly, and growing under a rock, and no one wants to turn the rock over,” said Dr. Michael Naylor, the psychiatrist in charge of Illinois’ review program, who recently struggled to get responses from other states for a paper he is writing on the topic.

Pacifying troubled kids
Some parents and advocacy groups say child welfare authorities routinely resort to drugs to pacify foster children without fully considering non-medication options. Among the aggrieved parents is Sheri McMahon of Fargo, N.D., whose son Willy was in foster care for 28 months from 2001 to 2003 because of an inspector’s ruling that their home was substandard.

McMahon said Willy, now 17, had been diagnosed with multiple disorders and was taking an antidepressant when he entered foster care. But she said that in a residential foster-care facility, he was placed on five psychotropic medications simultaneously — becoming sleepy and overweight and developing breathing difficulties.

“When he came back home, his pediatrician and psychiatrist expressed concern about the number and doses of medications,” McMahon said. “It took many months to get them down to a level where he had a chance of attending school regularly.”

Child psychiatrists say a shortage of funds and resources complicate the already daunting task of effectively diagnosing and treating mental illness in foster children. One problem, Bellonci said, is a nationwide shortage of child psychiatrists, often leaving pediatricians to handle complex behavioral problems.

Bellonci helped Tennessee’s Department of Children’s Services — the target of a sweeping lawsuit — overhaul its procedures for psychotropic drugs after an investigation found that 25 percent of foster children were taking them, often without legal consent. Tennessee’s policies are now considered among the best, encouraging expert reviews of prescriptions and urging prescribing doctors to consult with the youth, caseworkers and the biological and foster parents before deciding on medication.

The issue is very much alive in several other states. Among them:

  • In Florida, child welfare officials will be reporting to the legislature within weeks on the effects of a 2005 bill that tightened rules on when foster children can be given psychotropic drugs. The law requires prior consent of a foster child’s parents or a court order before such drugs can be used. The bill’s approval followed a report concluding that mood-altering drugs were being prescribed to 25 percent of Florida’s foster children.
  • In Texas, outgoing state comptroller Carole Keeton Strayhorn issued a stinging report in December on psychiatric treatment of foster children, including the use of medication. “The picture is bleak, and rooted in profound human suffering,” said the report, which recommended hiring a full-time medical director for foster children and requiring prior approval for certain prescriptions. Some activists say the recommendations, 48 in all, are unlikely to be embraced by the task force studying them; state health officials say use of psychotropic drugs for foster children is already declining because of guidelines adopted in 2005.
  • In California, Assemblywoman Noreen Evans introduced a bill last month that would require the state to collect the necessary data to show whether foster children are being overmedicated. “Many foster youth have told me that they are given pills instead of counseling,” Evans said. “The state doesn’t track who receives prescriptions and why. We need to do that in order to prevent abuses.”

Oversight and data collection is complicated in California because the medication regulations are handled by county courts. Dr. George Fouras, a psychiatrist hired to review foster-care prescriptions for San Francisco County, said the overwhelming majority of medication decisions are proper, and he has rejected only four out of many hundreds. But he said child-welfare systems nationwide are overloaded, sometimes tempting authorities to look for quick fixes instead of ensuring detailed mental-health evaluations.

  • In New York City, the public advocate — who serves in a watchdog role — asked child welfare officials three years ago for data on the use of psychotropic drugs in the foster care system. The data is still not available, although Assistant Commissioner Angel Mendoza of the city’s Administration for Children’s Services said a database should be ready later this year.

Mendoza said his agency has strict procedures governing the use of powerful medications; activists nonetheless worry that they are used too often.

“Children who are having normal reactions to the trauma of being separated from their families are often misdiagnosed or overdiagnosed as suffering from psychiatric problems, and the system is too quick to medicate,” said Mike Arsham of the Child Welfare Organizing Project. “It’s a chemical sledgehammer that makes children easier to manage.”

Among the New York parents sharing that view is Carlos Boyet, who says his son was routinely and unnecessarily medicated, at one point suffering an overdose, while bouncing through several foster homes as a toddler.

The boy, Jeremy, had been taken away from Boyet’s ex-girlfriend; Boyet eventually established paternity and was able to gain custody of his son, then 6, in 2005.

“It’s crazy,” Boyet said. “A child is acting out because he was moved away from his parent, and you’re going to medicate him because of that? It’s not right.”

Some child psychiatrists are concerned about a possible overreaction against the use of psychotropic drugs, saying many foster children genuinely need them.

Hurdles to thoughtful diagnosis
However, leading psychiatrists acknowledge the many hurdles to coming up with thorough, thoughtful diagnoses for children who have been wrested from their own families, often shift through multiple foster homes and perhaps have no appropriate blood relative with whom to consult regarding treatment.

“More times than not, kids do not get a really adequate psychiatric evaluation,” said Dr. Robert Abramovitz of the New York-based Jewish Board of Family and Children’s Services.

“There is such a lack of good psychiatric services, and you have the pharmaceutical companies and managed care companies saying, ’Medicate, Medicate,”’ Abramovitz said. “That’s all they want psychiatrists to do. They don’t pay for anything else.”

Referring collectively to child psychiatrists, he added, “We do not want to be pill-vending machines. But the alternatives aren’t there.”

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