From The Oregonian, November 25, 2007
Oregon’s children – More than a fourth in state care get psychiatric drugs, with little training, oversight or review
An Albany foster mother recalls a 5-year-old boy medicated so heavily that he lived in an endless cycle of sleeping, rising for a meal, taking his pills and collapsing back into bed.
A Salem nurse who volunteered at a camp for Northwest foster kids last summer says she was shocked at the hundreds of psychiatric drugs she gave out to children every day.
A Multnomah County court officer tells of a teen in foster care who loved skateboarding but became so overwhelmed by his meds that he could barely hold his head up.
More than one in four Oregon children in foster care — some as young as 2 — are being given powerful psychiatric drugs developed to treat depression, anxiety, trauma and other mental health issues.
The medications include potent drugs such as Prozac and Zoloft. Many have not been approved for children, their side effects can be severe and there’s little evidence about how they might act on developing brains and young bodies.
About 2,400 kids a year in foster care are on psychiatric drugs. The medications can help troubled children who suffer abuse, neglect or other trauma. Even so, The Oregonian found that children in foster care took psychiatric drugs at a much higher rate — more than four times higher — than other Oregon children.
The state’s child welfare system creates incentives for foster parents that could encourage psychiatric drug use: The meds make the kids less trouble. And the foster parents can be paid double for the “special needs” of kids on psychiatric drugs.
The state, the legal guardian for children in foster care, does little to monitor the use of psychiatric drugs.
“Nobody is tracking it in a way that makes sense,” says Judge Nan Waller, the chief family law judge in Multnomah County. “We need to make sure we have the level of oversight our children deserve.”
Tannie Mowdy has eight children younger than 18 living in her tan, two-story house on a country acre six miles east of Albany.
A 14-year-old girl takes Prozac, and two boys, ages 12 and 13, take Wellbutrin — anti-depressants often prescribed to children in Oregon foster care.
Mowdy, who has been a foster parent to nearly 300 children in 26 years, says psychiatric medications have helped one teenage girl in her care finish high school and a boy in her home “slow his mind down” so he can focus on even the most routine tasks.
Sitting in her dining room staced high with puzzles, games and toys, Mowdy says what she knows has come from talking to her doctor and pharmacist.
Sometimes, she says, it’s a “hit-or-miss learning process.”
Mowdy hasn’t forgotten the 5-year-old boy who came to her home several years ago with a bottle of clonidine, a blood pressure medication that’s often used to calm children down.
The little boy would get up in the morning, eat breakfast, take his pills, and then go back to bed for a nap, Mowdy remembers. He’d repeat the routine at lunch.
“I went to the doctor and said, ‘We’ve got to get this kid off of this.’ ”
The doctor was happy to comply, Mowdy says. He had put the child on medication to control unruly behavior and so he wouldn’t be kicked out of his foster home.
One girl came to Mowdy’s home on eight psychiatric medications, she says. “Too many kids take too many medications.”
The Oregonian used the state’s public records law to discover how many children under state supervision are on psychiatric medications.
The records show 29.4 percent of children in foster care were on at least one psychiatric drug in a recent 12-month span.
The newspaper then asked the state’s Medicaid program how many of the 203,000 other children also covered by the Oregon Health Plan had been on a psychiatric drug. The answer: 6.3 percent.
University of Maryland professor Julie Magno Zito, one of the nation’s leading researchers into psychiatric drug use among children in foster care, says it’s hard to judge the rate. States must have strong standards and oversight, she says, especially because the effects of these drugs on children aren’t well understood.
“You start treating the side effect of drugs with other drugs, and it becomes a vicious circle.”
People who work in Oregon’s child welfare system say they’ve been surprised by how young some kids on medications are.
Kevin George, foster care program manager at the Department of Human Services, says he remembers a child as young as 18 months receiving a psychiatric drug, although he can’t recall the specific drug or circumstances.
But Medicaid records show more than half of kids in foster care who receive the medications are about 13 or older.
Lynn Lanham, a nurse at Salem-Keizer public schools, saw that firsthand last summer when she volunteered at Camp to Belong, an Idaho camp for kids 8 to 20 years old who live in Pacific Northwest foster homes.
Of the 96 kids at Camp to Belong last June, about 60 percent came with psychiatric meds.
“I was struck at how many psychotropics I was giving to these kids,” Lanham said. “I have been a camp nurse at other camps and never given that much.”
Steve Lindeman, a field manager for the Citizen Review Board in Multnomah County, which oversees child welfare cases, remembers a skateboarding teen who was energetic and excited the first time he met him.
When his case came up for review a few years later, Lindeman said, “He was on significant medications that created what some people referred to as the ‘zombie effect.’ ”
Lindeman was part of a group of experts formed in 2004 after judges and other court officials questioned the number of psychiatric drugs prescribed to children under state supervision.
The state refused to release the group’s work, but The Oregonian obtained it from other sources. It shows big problems.
The group discovered medication is not being managed properly, training for caseworkers and foster parents has been discontinued, and systems for tracking medications are not in place, according to minutes from an October 2004 meeting.
One recommendation: Take away foster parents’ power to give a child psychiatric medications without state consent.
Why?
The group’s report says “foster parents may have an incentive to describe their foster children’s mental health issues with a very negative bias in order to obtain serious mental health diagnoses and consequent prescriptions.”
That’s because foster parents can receive higher monthly payments from the state if a child has “special needs” — and children taking psychiatric drugs often earn that designation. These payments can average $600 a month, more than double Oregon’s regular rates.
“If the child is off the medication, there would be less money coming to the home,” Lindeman said. “We don’t think that’s a good setup.”
George, the state’s foster care manager, said he isn’t sure why the group’s proposal to change the consent rules wasn’t adopted. “Maybe we should revisit that.”
Foster parents are required to seek consent for other medical treatment — for example, if a child needs his tonsils out.
Don Darland, from the Oregon Foster Parent Association, says he wouldn’t mind if the same rules of consent applied to a child starting psychiatric drugs.
The state is “the legal guardian, and they have to be involved,” he says. “We are parenting that child 24/7, and we need to be in the conversation, too.”
Darland has cared for more than 50 children in his home and says about half were prescribed psychiatric meds. “I’m not going to advocate for a medical restraint unless that child really needs it.”
The state did adopt many of the expert group’s recommendations when it wrote new rules in May. The rules encourage second medical opinions in cases where the children are younger than 6 or where kids are on more than three psychiatric drugs at once.
Other states have panels of doctors or teams of nurses to review drug use. Oregon has Teri Shultz, one lone nurse to consult when children in foster care are taking psychiatric drugs.
Before the new policy was adopted this spring, Shultz recalls seeing only one case in the past 10 years.
Since May, she’s reviewed about 40 cases, and referred almost all of them for second opinions. That’s about 3 percent of foster children on psychiatric drugs — still far fewer than experts recommend. The group advising state officials wanted children with more than two medications to have their cases reviewed.
Under that proposal, about 28 percent of kids would have their prescriptions reviewed, state records show.
Dr. Bruce Goldberg, the state Human Services director, says the standards should be even tougher.
As a physician, Goldberg says, he thinks ideally every child in foster care on more than one psychiatric drug should get a second look.
Goldberg wasn’t familiar with his agency’s policy until The Oregonian raised questions about it. He asked Dr. Nancy Winters, a professor and child and adolescent psychiatrist at Oregon Health & Science University, to review the new state rules to see whether they are sound.
The state policy is inadequate, Goldberg says.
“It needs to be re-evaluated.”
Waller, the judge who hears the custody cases of hundreds of children in her courtroom every year, says she’s seen how psychiatric drugs have helped some children. But she’s also heard a teen complain of drowning in “an alphabet soup of medications.”
Everyone needs to look for other ways to ease the trauma for these kids, she says. “Under our watch, we need to make sure we don’t make the problem worse.”
Brent Walth: 503-294-5072; brentwalth@news.oregonian.com; Michelle Cole: 503-294-5143; michellecole@news.oregonian.com