Nov 25, 2007 01:00 AM

Foster kids’ meds get scant attention

Oregon’s children – More than a fourth in state care get psychiatric drugs, with little training, oversight or review

BRENT WALTH and MICHELLE COLE

The Oregonian

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

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Part II

The Oregonian

Law requires notification when meds are prescribed

Following through on the state’s legal requirements is “a relatively rare phenomenon,” an official says

Sunday, November 25, 2007

BRENT WALTH and MICHELLE COLE

The Oregonian

Many of the adults responsible for children in foster care don’t know about Oregon’s Bobby Jackson law.

JeanEttel, Bobby’s first-grade teacher at Willard Elementary, says sheremembers 7-year-old Bobby as a well-behaved boy who was small for hisage.

Bobby still had his baby teeth, says Ettel, who also remembers that he liked to play ball.

She didn’t know he was taking a drug to moderate his behavior.

Bobbywas given imipramine, an antidepressant doctors had recommended tocontrol his daytime tantrums and nighttime sleeping problems.

“Sometimes his little hands would shake when he would write,” Ettel says.

OnJan. 5, 1993, Bobby collapsed at his Eugene foster home after runninguphill from school. An autopsy found a lethal dose of imipramine in hisbody.

The law that the 1993 Legislature passed following Bobby’sdeath requires foster parents to notify the Department of HumanServices within one working day when a child in their care gets amental health prescription.

Then, caseworkers must notify achild’s parent, lawyer and court-appointed special advocate — or CASA– about why the drug is being given, the dosage and possible sideeffects.

But that doesn’t always happen.

Steve McCrea,program coordinator with CASA for Children, Multnomah and Washingtoncounties, says notification is “a relatively rare phenomenon.”

The law also allows a child’s parent, lawyer or advocate to petition a judge to order a second opinion.

“Quite frankly,” says Kevin George, the state’s foster program manager, “that doesn’t happen very often.”

Georgesays notification is required by law, but it still depends upon theindividual foster parent and caseworker. There’s no statewide databasetracking whether children get the follow-up they need.

Bobby’s teacher says she’s sorry to hear that.

Thelast time Ettel saw Bobby, he was preparing to race a bigger boy in hissame class to the foster home where both of them lived.

Ettel gave Bobby a head start.

“He stood at the door and waved at me and said: ‘Goodbye. I’ll see you tomorrow.’ “

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Part III

The Oregonian

Foster kids, meds merit exam

Oregon – Lawmakers say they are determined to fix the lack of oversight of psychiatric drugs

SALEM — Oregon lawmakers said Monday that they’re determined to fix problems with the state’s oversight of psychiatric medications given to children in foster care.

Oregon Senate President Peter Courtney, D-Salem, said the Legislature will hold hearings when lawmakers reconvene in February to examine how well the Department of Human Services supervises the use of mental health medications.

“The state is responsible for the well-being of these children,” Courtney said in a statement. “We need to determine if agency policies are putting the health and potentially the lives of some of our most vulnerable citizens in jeopardy.”

Courtney’s announcement follows a story in The Sunday Oregonian that found more than one in four children in foster care in Oregon take drugs to treat depression, anxiety and other mental health problems.

The newspaper found that 2,400 children in foster care received these drugs in a recent 12-month span — a rate more than four times that of other Oregon kids.

Experts say the drugs can help troubled children in foster care, who often face higher rates of mental problems. The kids have faced grave abuse and neglect or were exposed to drugs and alcohol before they were born.

The newspaper found, however, that the state’s child-welfare system does little to monitor the use of these medications. And state officials ignored warnings from a panel of experts who raised concerns about allowing foster parents to make decisions to medicate children without state consent or adequate medical review.

Dr. Bruce Goldberg, the director of the Department of Human Services, asked for a review of the rules governing the use of psychiatric drugs by children in foster care after The Oregonian raised questions about the practices.

Rep. Wayne Krieger, R-Gold Beach, spent the past two years working with a bipartisan group of legislators on ways to improve the state’s child protection system. He said he welcomes hearings.

“There might be times I disagree with Senator Courtney, but I think he’s right on,” said Krieger, who also spent more than a decade as a foster parent.

Rep. Carolyn Tomei, chairwoman of the House human services committee, said she was alarmed by how little medical review the state’s child-welfare system provides as a safeguard for children in foster care placed on psychiatric medications.

“We have just one lone nurse to do the job,” said Tomei, a Milwaukie Democrat. “This is just shocking.”

Tomei said she served as a foster parent and later worked for the state supervising foster homes.

“It’s understandable these children have their own sets of problems, and they might be on medications,” Tomei said. “What’s appalling to me are the sheer number of children on several drugs, and that the state seems to have no oversight.”

Rep. Sara Gelser, D-Corvallis and vice-chairwoman of the committee, thinks the Legislature ought to consider whether children in foster care are getting appropriate screening for conditions, such as autism, that might be better off with some other type of treatment.

Gelser also has questions about how well the state’s system monitors the diagnoses and treatments for children in foster care.

“What is the point of administering the medication to a child? Is it for their well-being? Or is it management of the child within the system?

“If it’s the second,” she said, “we’re failing the children.”

Gov. Ted Kulongoski “takes very seriously the state’s responsibility for the health and welfare of the children in foster care,” his spokeswoman Patty Wentz said Monday. “We support the DHS internal review and the Senate’s review committee and will review the findings carefully.”

Courtney, the Senate president, also said he takes the Legislature’s oversight role seriously.

He is “appalled” by the newspaper’s report that a law passed in 1993 — after a 7-year-old boy in foster care died of an overdose of a drug meant to calm him — is being largely ignored. He said the story shows the need for better legislative supervision of the state’s human services agency.

“We have to find out what the hell we’re dealing with,” he said.

Michelle Cole: 503-294-5143; michellecole@news.oregonian.com

Brent Walth: 503-294-5072; brentwalth@news.oregonian.com

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Oregonian – Fact Box:

Psychiatric drugs and children in foster care

29.4 percent of children living in foster homes were prescribed at least one psychiatric drug over a 12-month period — a rate 41/2 times that of other Oregon children covered by Medicaid.

The drugs included Ritalin, prescribed for attention deficit disorders, as well as anti-depressants such as Prozac and Zoloft.

Unlike some states, Oregon allows foster parents to ask a doctor to start a child on a new drug without consent of the child’s parent or caseworker.

Foster parents must disclose when they put a child on psychiatric drugs and keep medication logs — but those rules aren’t always followed.

The state lacks a database to help caseworkers track what psychiatric drugs a child may be on.

To read The Oregonian’s stories on the medications used by children in foster care homes, see http://www.oregonlive.com/politics/oregonian/ For information on the Legislature’s February session or to contact your state lawmaker, go to http://www.leg.state.or.us/

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For original articles:

Part 1: Foster kids’ meds get scant attention.

Part 2: Law requires notification when meds are prescribed.

Part 3: Other states have tighter rules for medication use.