CARETAKERS ROUTINELY DRUG FOSTER CHILDREN

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.

Checked-by: jwjohnson@netmagic.net (Joel W. Johnson)