Monday, December 05, 2011

Overmedication & Foster Care

As I flipped through the channel guide Friday night I found a show I didn’t want to watch but knew I had to. As a foster parent advocate I had to see how exactly 20/20 was going to handle the issue of the (over)use of psychotropics with foster children. I want to say it’s an issue that most, if not all, foster parents are at least aware of though the fact that some foster parents end up having their children medicated unnecessarily begs the question whether they do so intentionally, out of ignorance, or out of a lack of empowerment. If I had to guess I’d say it happens for all three reasons but even still I can’t imagine there is a foster parent out there who is truly oblivious to this issue.

So I recorded it. Then I watched a movie with a particular thieving Grinch with my son, nephews, and niece that didn’t end until 11pm. Of course being Mie I couldn’t go to bed until I watched the show, so I watched it late Friday night.

The things parents do on a Friday night.

Anywho – Penny over at reminded mie of the episode when I caught up with her this morning. Check out her comments here.

As I began watching this story I was immediately filled with passion, even after 11pm on a Friday night. I felt angry at the system, compassion for the children, and was ready to pounce at 20/20 at any minute if they chose to attack foster parents or be decidedly biased on an issue that is very complex and ultimately affects real children out there. I was generally impressed. In my opinion, they handled the topic fairly well. I did not like that they toed the line on exploiting current and former foster children to make their point, but I’m also not sure how well they would have been able to communicate the facts without using real stories and therefore real children. I wasn’t happy with the fact that foster care was again gaining negative attention in the media. I hate that so many people only get to see the negative aspects of "the system" because that's what makes it on the news aside from the occasional Adoption Day coverage. But overall I think they did a good job at covering an issue, some of the contributing factors, and some of the things regular people can do to help in a 30 minute segment.

Essentially the angle the story took was that doctors and the supporting foster care system including Medicaid and the Pharmaceutical companies are targeting foster children for psychotropic medications that may or may not have been approved for children who may or may not need medication at all.

Here’s my analysis of the situation in a nutshell. Foster children have faced harm, not only from the original caregivers who either abused or neglected them but also from the loss of their original family that happened when they were removed and placed into foster care in the beginning. That harm results in hurt that manifests itself in a variety of ways. In some cases, add prenatal and other alcohol and drug exposure and you end up with a child who very may well have some significant mental health (among other) issues that need healing. This “need for healing” often manifests itself with difficult behaviors from the children including severe depression with suicidal thoughts and actions, lack of age-appropriate self-control, violent tendencies, various forms of delay including developmental and emotional, lying, stealing, running away, and on-and-on. Basically, the “need for healing” is hard on the kid and that makes the job of a foster parent often, but not always, involved if not difficult.

Where does someone go for healing? A doctor. Foster parents are generally allowed to seek medical care for their children with very little intervention from others, like caseworkers. They are also generally required to follow doctor’s orders. Typically, doctors who will take the government funded health insurance provided to foster children are in very short supply. This means a foster parent will tend to take the child to the doctor to address behavioral issues, a doctor who is generally receiving less money than with other patients, a doctor who doesn’t have much time to spend with the child because they are cramming as many children into their office to make-up for the lower payments. Not only do doctors have little time with (and therefore know little about) the child but often foster parents don’t have “the whole story” about the children even IF they had the opportunity to communicate it to the doctor in full. Therefore, the doctor often ends up either referring out to a specialist (psychiatrist, etc., the better choice) or more often will diagnose a “common” disorder like ADHD and prescribe the “common” prescription like Ritalin. If that happens, the foster parent usually MUST provide that drug to the child as prescribed. End of story.

It doesn’t have to be that way. Good foster parents will usually go way beyond that “path of least resistance”, but that takes a lot of work. For example, a foster parent might take the child into a psych evaluation. In order to do that in my neck-of-the-woods, she’d first have to get authorization from the caseworker, who then must issue a referral (if and only if the child hasn’t had one already in the past 12 months). A referral can take a long time. Then the foster parent has to wait for the caseworker’s chosen psychologist to call to set up an appointment.(hopefully they went with a psychologist…if not a good foster parent will fight that battle before moving forward). All of this will take weeks if not months. In the meantime the child is still having the behaviors and is “crying” for help. Then a foster parent might have the opportunity to get a proper eval, which involves several hours of prep-work from the foster parent and at least an hour or two with the psychologist. A diagnosis might then be rendered which will go to the caseworker (usually) not the foster parent, so the foster parent must wait until further contact before doing anything else. Hopefully at this point the child will receive the services needed.

The process to get therapy of any kind (developmental, speech, play, talk, etc.) looks much like that, but is separate for each type of therapy. In other words, you’d “rinse and repeat” for each type of therapy the child needs. There are a few options for efficiency in the processes, but generally you can imagine what it takes to get proper treatment for the child.

Now, in terms of medication, there are things a foster parent can do to avoid that too, if it is not appropriate for the child and his/her situation. To start, avoid taking your child to the medical doctor for behavioral challenges. It is a reasonable expectation that if you take the child to the M.D. they will lean toward a prescription solution rather than therapy, as an example. You can’t blame them, that is what their training tends to be. If a doctor visit is appropriate, there are still things that the foster parent can do to avoid unnecessary medication. First, find a good doctor. Second, get as much information about the child as you can. Third, research, research, research. Look-up diagnosis criteria for common disorders. Look-up your child’s symptoms and behaviors. Though I wouldn’t recommend self-diagnosis, at least it will give you an understanding on what’s out there so you can ask appropriate questions of the doctor. Fourth, ask questions and give input at the doctor visit. Insist the doctor spends time with you and the child. If they are getting ready to prescribe something, ask if there is a natural remedy or something besides medication that you can try. It’s not that medication is not appropriate in any circumstance, but the foster parent (and any parent really) should be looking at the holistic solution, especially with behavioral challenges. Fifth, as with any diagnosis – get a second opinion.

Finally, my last advice on being prescribed psychotropic medication – almost without reservation, if a psychotropic is prescribed you must seek additional therapeutic support. This is true of anyone, but especially with foster children who will understandably have things that need to be addressed with therapy. Medication may be needed in the beginning to help therapy be successful, but in most cases it is not and should not be the ultimate solution. If the root issues are not addressed and/or alternate solutions are not taught (life skills, behavioral medication, etc.) true healing won’t happen – the child will just be drugged into submission.

I personally have not had much experience with children in my care being overmedicated with psychotropics. My kids have all been too young to be taking them and I would have thrown a fit. I will say though that they have all come to me with other types of medications they did not need that appeared to be freely handed out in previous placements or while they were with their family of origin. Most have come to me on prescription level allergy medication, stomach medication (prevacid-type), inhalers, breathing treatments, antibiotics, and decongestants. Thankfully most of the doctor orders said “as needed” and I was able to treat as such – turns out most of them didn’t need anything. In case you were wondering, even though they were as needed I ran my choice to discontinue use by the doctors first; after all I myself am not a doctor and don’t claim to know everything about health. Nevertheless I could see how if I had older children it would be very easy for me to end up with more medication than necessary, psychotropic or not. I know for my oldest kiddo, if I had wanted to I could have found an MD willing to diagnose him with something to get him on some sort of psychotropic to help deal with his behaviors. That’s a crying shame.

Unfortunately, the episode did not get into a few things it probably should have. First, there are foster parents out there who try to get their children on medications. Not only does this “make the kids easier to handle” but also often qualifies the children with a higher service level which often qualifies them for higher foster care subsidy (read: foster parent pay). A “good” option for foster parents “in it for the money”. I’m glad it didn’t talk about this though – I think that is fairly rare in comparison to other reasons for overmedication and gives us good foster parents a bad rap. Generally the show gave foster parents and those willing to adopt the benefit of the doubt, encouraging more people to get involved. Bravo. I do think they missed an opportunity (though I understand why) to talk about the real need for some children to be medicated and the severity of some of their issues they face in foster care. I think they could have done a lot of good talking about some of the real things foster children face and the way it affects their lives – things like attachment disorders, affects of drug and alcohol abuse, and the hope they have for a better life when they get the right support for growth. They could have also done a better job focusing on how hard it is to fight the system when you’re a foster parent and how seemingly everyone’s hands are tied, even the doctor’s to a degree rather than focusing so much on the impact of the pharma’s and unethical doctors. Generally most people are trying to do good. Generally, we just need to come up with ways we can do it better.

Foster care is a delicate situation, it really is, with so many moving parts and added complexity to "normal" parenting that a 30 minute show just can't do any topic justice really, but I’m grateful they tried. The important thing is as a community we keep this issue out in the open rather than in the dark so people continue to be aware that overmedication can be an issue and there are other options out there to help foster children learn to thrive despite their situation.

After all – that’s what we foster parents are trying to do, right?

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