SCF often acts cavalierly in mandating psychotropic drugs for children, says the LA Times..... >>> Los Angeles Times >>> Sunday, May 17, 1998 >>> >>> http://www.latimes.com/HOME/NEWS/STATE/t000046480.html >>> >>> Caretakers Routinely Drug Foster Children >>> By TRACY WEBER, Times Staff Writer >>> >>> State: Psychiatric medication could do irreparable harm, >>> experts say. Often, consent is lacking. >>> >>> >>> >>> 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 >>> >>> Copyright Los Angeles Times >>> >>>