The Overmedication of Foster Youth

Every year, thousands of children that are taken away from their home due to parental neglect and abuse are placed in child welfare programs such as foster care only to face even more neglect and abuse. Though the idea behind foster care is noble, giving children a second chance at life in a home with parents who are able to love and care for them, its existent implementation unfortunately has many shortcomings. In fact, the foster care system has frequently been denounced by victims, witnesses, and advocates for failing to adequately meet the needs of children and providing them with proper care. On one hand, are underpaid and overloaded social workers employed in governmental agencies that are exerted beyond their expertise and capacity. On the other hand, an overwhelmingly large number of caregivers who have no true interest in helping these children and assume care of them strictly because of the financial benefits of foster parenting. The union of the two hands create a metaphorical chokehold around children that have already lived through unimaginable kinds of horror and trauma.

One of the worst issues of the foster care system is the ways in which it perpetuates cycles of poverty, racism, drug abuse, incarceration, and violence. It is structured in such a manner that its functioning inherently targets and wages war on marginalized and oppressed groups of people. This is for example illustrated in the practice of mass removal of children from families that pertain to lower-economic classes in which communities of color are overrepresented. The child welfare system somehow fails to distinguish between neglect and poverty. Even though child abuse and/or neglect can happen at hands of parents of any socio-economic standing, it is not handled the same way for everyone. While belonging to a particular race and class shields certain children from ever having to face foster care, many of those who are denied that luxury are taken away from decent, loving parents because they are poor. This widespread practice is solely based on the assumption that disadvantage (housing instability, difficult neighborhood, lack of access to resources) equates with neglect. Instead of helping poor parents respond to their needs and that of their children, the child welfare system punishes them by separating their family. Not only do these parents watch the system take away their children, but they also watch it bring them to live with other adults, to whom it ironically does provide the financial means necessary for the care of the children.

In contrast, many children that are placed in foster care in response to them facing difficulties that do in fact fall under the categories of neglect and abuse. These include but aren’t limited to physical abuse, sexual abuse, truancy, medical neglect and parental incarceration etc. Children who are taken into the foster care system are children who have been dealt an unfair hand in life, more often than not due to choices and circumstances that are out of their control, sometimes that are even out of the control of their parents. Regardless of the root of their causes, it is these children’s who eventually have to carry the burden of the consequences of those circumstances. Unsurprisingly, this reality renders foster children particularly vulnerable to emotional disorders, psychological disorders, and chronic illness. According to a 2014 First Focus On Children publication “nearly 60 percent of children in foster care experience a chronic medical condition, and one-quarter suffer from three or more chronic health conditions. Roughly 35 percent have significant oral health problems. In addition, nearly 70 percent of children in foster care exhibit moderate to severe mental health problems, and 40 percent to 60 percent are diagnosed with at least one psychiatric disorder.” Their considerable exposure to abuse and neglect results in trauma that creates very particular needs in foster children. They tend to deal with a greater number of physical and mental health problems in comparison to non-foster youth.

While non-foster youth typically rely on their parents and other caregivers to insure that their health is properly looked after, in the case of foster youth, it is to the state’s child-welfare agency, that chooses the child’s foster residence, to also organize that they receive health services they might need, including mental health services. The problem is that the caseworker assigned to each child is statistically also managing anywhere from 10 to 100 other cases, making it difficult for them to ensure that each individual child is provided adequate mental care.

Due to the lack of resources, children in foster care don’t sufficiently undergo appropriate screening, assessments, and diagnoses and as a result, seldom receive effective treatment. The treatment that a majority of foster care youth receive is limited to the excessive prescription of psychotropics drugs. Psychotropics are medications that influence the central nervous system (which consists in the brain and spinal cord) to create changes in thought, perception, mood, and behavior. It is estimated that approximately 120,000 children in foster care are prescribed at least one such medication. Although they can help reduce symptoms of various mental health conditions, the increasing rate at which psychotropics are prescribed to foster children and the potentially hazardous combinations and amounts, despite the limited evidence with respect to short and long-term safety, continues to raise concern among researchers, advocates and even providers. While foster children are more likely than non-foster children to face emotional and behavioral disorders, the rates at which they are prescribed psychotropics, about three times as much as other children, is significantly disproportionate. The inadequate and questionable prescribing methods that have been documented in child welfare cannot be explained by this alone.

In a 2015 article by Marian Wright Edelman titled Overmedicating Children in Foster Care, she states “On any given day nearly one in four children in foster care is taking at least one psychotropic medication—more than four times the rate for all children. Nearly half of children living in residential treatment centers or group homes take psychotropic medications. Children in foster care are more likely to be prescribed multiple psychotropic medications at very high doses, although research shows higher doses can result in serious side effects” (Edelman, 2014). Although there is no scientific evidence that substantiates the simultaneous use of five or more psychotropic medications, even in adult populations, this is the treatment plan established for hundreds of foster children. The article also tells us the story of 10-year-old Ke’onte Cook. Although he had never been diagnosed with ADHD, Bipolar Disorder, and seizures, Ke’onte was being treated with a dozen different medications to address these conditions. Thankfully, he was adopted by parents who suspended this regimen and instead had him rely on therapy, a method that completely transformed Ke’onte. (Edelman, 2015) Although mental health issues and the adequate treatment for them vary across individuals, Ke’onte’s experience demonstrates that many foster children's needs are improperly addressed due to the overreliance on multiple psychotropic medications. Polypharmacy is not the only matter of concern in regard to the system’s approach to mental health treatment. Children in foster care are also prescribed psychotropics at levels that increase the probability of serious and potentially fatal health risks. These prescriptions often surpass the maximum doses approved by the Food and Drug Administration (FDA) guidelines, as well as the maximum doses recommended for children and adolescents based on medical literature. There exists no evidence that proves that this type of regimen is helpful, in fact, it does not even increase the benefit of the medications. On the contrary, health experts have confirmed that it does increase risks of adverse side effects that may include but are not limited to hallucinations, nightmares, suicidal thoughts and even death.

The little evaluation or lack thereof of the harm that they can cause when prescribing drugs to foster children is a violation of these children’s civil rights as it endangers their health and lives. Psychotropics are even prescribed to infants, as reported in a report by the Government Office of Accountability (GAO) on how Additional Federal Guidance Could Help States Better Plan for Oversight of Psychotropic Medications Administered by Managed-Care Organizations. It is supposedly done for psychiatric reasons, however, the GAO found that there is no documentation to justify those prescriptions. “Experts found in one infant case that the child was prescribed an antidepressant (amitriptyline) at 9 months of age, and a prescription for an ADHD medication (clonidine) was added at 15 months of age” (GAO, 2014). According to this study, there is no evidence that supports the use of amitriptyline to treat self-injurious behavior in children or in any age group. Furthermore, this medication can have many effects, one of them being cardiac side effects, and has even been linked with sudden death in young children. Worse, the toddler suffered from corneal ulceration that amitriptyline can cause or worsen. The child’s agitation was in fact exacerbated. This is unfortunately one of too many examples of the range of poor prescribing practices that foster children are subjected to. Following the death of Gabriel Myers, who hung himself in his foster family’s bathroom, an investigation proved that the use of the psychotropic drugs he had been prescribed contributed to his death. “His foster father said the doctor who prescribed the many drugs Gabriel was taking—some so strong that even the pharmacy filling them raised red flags—would spend no more than five minutes with the little boy before sending him out the door with another prescription.” (Edelman,2014). Gabriel was seven years old.

In a 2018 class action lawsuit against the state of Missouri, the advocacy groups Children’s Rights, National Center for Youth Law, and St. Louis University School of Law Legal Clinics further demonstrated that psychotropics are overprescribed to foster children to a harmful extent. 'A 12-year-old girl identified as a ‘K.C’ in the lawsuit was prescribed as many as five psychotropic medications without informed consent, according to court records. The girl suffered from shakes after allegedly being given a combination of medications that included the antipsychotic Abilify, the ADHD drug Strattera and the powerful psychotropic drug Seroquel” (Reynold, 2018).reveals that K.C, who was often involved in fights at her residential facility, became noticeably less aggressive once she stopped taking the psychotropic Seroquel. The complaint is that administrators prescribed the drugs to keep the children in a sedated state rather than a valid medical purpose.

As demonstrated by the stories of both K.C’ and Ke’onte, the needs of foster children, especially in regard to mental health, are often misapprehended. This typically results in ineffective treatment in one of two ways. The first possibility, misdiagnosis, is that the child is not diagnosed properly and is thus either treated for something they don’t have, or in the case of a partial misdiagnosis, not treated for all that they have. The second likely occurrence a correct diagnosis, but one where child receives treatment that is either incomplete, (for example drug prescriptions but no non-pharmacological intervention) or inadequate for their particular situation (Ke’onte for example did need mental health treatment but it was therapy, not medication that worked best for him). When the untreated mental health difficulties of children in foster care also manifest as behavioral problems, they are often punished because their conduct is attributed to insolence and rudeness, rather than to the need of better care. Treatment ineffectiveness, as well as the behavioral problems that it can cause and the abuse that can result from them, is sustained by lack of appropriate monitoring and management of psychotropic treatment. The American Academy of Child and Adolescent Psychiatry states in their Guide for Community Child Serving Agencies on Psychotropic Medications for Children and Adolescent, that “When psychotropic medication is indicated there should be informed guardian consent and youth assent with consistent medication monitoring protocols and procedures” (AACAP, 2012). However, in the aforementioned study led by the GAO, it is reported that “the monitoring programs of these states for psychotropic medications provided to children in foster care varied and

fell short of best-principles guidelines published by the American Academy of Child and Adolescent Psychiatry (AACAP)” (GAO,2014). Consequently, in addition to being prescribed dangerous combinations and doses of medication, many children in the foster care system are forced to take medication that they don’t actually need and that is thus harmful rather than beneficial to them. As stated by Ann Maxwell, an Assistant Inspector General from the Department of Health and Human Services, “These children are at greater risk of not getting the medications they need, but equally important, they are at risk of getting powerful medications that they do not need” (Alonzo-Zaldivar, 2018).

Foster children, who have been traumatized and uprooted countless times, admittedly have greater mental health needs than non-foster children. However, the rate and dosages at which they are prescribed psychotropics, despite the substantial evidence of potentially dangerous side effects, indicates that there is a motivation other than just apprehending those needs. In addition to the issues of negligence and malpractice, the overmedication of foster children is also rooted in the system’s (including state, caseworkers, and foster parents) search for convenience. Psychotropic medication has the capacity to numb people who take them, thus masking symptoms of unwellness. The influence of psychotropics on mood can render docile the most aggressive children. . The overmedication of foster care children aims to sedate them, as a form of behavior control. It causes a lethargy so extreme that older foster children report dozing through much of their young life. In the 2014 article, Drugging Our Kids, George Stewart, a child psychiatrist who has worked with foster children for 40 years declares “It really is drugging them.” (DE SA, 2014) Overmedication of foster kids works in favor of the state because when the drugs mask the symptoms, the need for a comprehensive biopsychosocial treatment-which would require human and financial investments in appropriate screening, diagnosis, and interventions measures -becomes camouflaged. Moreover, the common knowledge that they statistically have greater mental health needs, along with their extensive Medicaid coverage through title IV-E, makes foster youth the perfect guinea pigs. Judge Michael Nash who presides over L.A county, the nation’s largest juvenile court states “We are experimenting on our children.” (DE SA, 2014). Caseworkers also benefit from the overmedication of foster youth as it indirectly minimizes their workload by decreasing caregiver complaints and gives them less kids to move kids from home to home. Overmedication works in favor of foster parents that don’t have genuine interest in the children’s wellbeing. They’re able to do less parenting while continuing to be financially compensated. The people that are disadvantaged are the foster children who suffer the negative side effects, both mentally and physically such as rapid onset obesity and diabetes amongst other things (DE SA, 2014). There is also the less extensively studied possibility of long-term effects that include persistent tics, increased risk of suicide and brain shrinkage (DE SA, 2014).

In an ironic twist of fate, the only people that this system endangers by overusing psychotropics are the very same people it is in place to protect. The use of psychotropics is not inherently inadequate, it is the way they are used that is ineffective. Psychotropic medications are only one component of what successful treatment of mental health disorders in foster care youth would mean. A comprehensive treatment, a biopsychosocial treatment would require making the necessary adjustments in the

child’s social environment, providing the child with trauma-centered therapy, prescribing the child with psychotropics if necessary, amongst other things. Appropriate care for those who would need it is crucial to the creation and sustainment of a better, more equitable society.

Sources

American Academy of Child and Adolescent Psychiatry. (2012, February). A Guide for Community Child Serving Agencies on Psychotropic Medications for Children and Adolescents. AAACP. https://www.aacap.org/App_Themes/AACAP/docs/press/guide_for_communitychild_serving_agencies_on_psychotropic_medications_for_children_and_ad olescents_2012.pdf

First Focus on Children. (2014, November 10). Overuse of Psychotropics in Foster Care. https://firstfocus.org/overuse-psychotropics-foster-youth

U.S. GOVERNMENT ACCOUNTABILITY OFFICE. (2014, April). FOSTER CHILDREN Additional Federal Guidance Could Help States Better Plan for Oversight of Psychotropic Medications Administered by Managed-Care Organizations (GAO-14-362). GAO. https://www.gao.gov/assets/gao-14-362.pdf

Children’s Defense Fund. (2018, May 16). OVERMEDICATING CHILDREN IN FOSTER CARE — Children's Defense Fund. https://www.childrensdefense.org/child-watch-columns/health/2015/overmedicating-children-in-foster-care/#:%7E:text=Nearly%20half%20of%20children%20living,group%20homes%20take%20psychotropic%20medications.&text=They%20can%20be%20effective%20treatments,a%20form%20of%20behavior%20control

Kutz, G. D. (2015, December 15). Foster Children: HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions [Reissued on December 15, 2011]. ..S. GOVERNMENT ACCOUNTABILITY OFFICE. https://www.gao.gov/products/gao-12-201#:%7E:text=HHS%2Dendorsed%20g 

Miglani, J. B., Scrivener, J., & Miglani, S. (2019). 2.23 Are We Overdiagnosing and Overmedicating Children and Adolescents Being Raised in Non-Parental Households and Foster Care? Diagnostic and Demographic Considerations in Children Raised in Parental Household Vs. Other Placement Settings. Journal of the American Academy of Child & Adolescent Psychiatry, 56(10), S184–S185. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6457445/

Reynolds, M. (2018, July 20). Foster Kids Suing for Overmedication Win Class Status. Courthouse News Service. https://www.courthousenews.com/foster-kids-suing-for-overmedication-win-class-status/

DE SA, K. (2014, August 24). Drugging Our Kids | Part 1: The Mercury News. The Mercury News. https://extras.mercurynews.com/druggedkids/