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Medicating Foster Kids: Not the Travesty It Seems?

The reality about foster children and medication is far more complicated than it appears in the political theater of a congressional hearing, or in television news shots of sad-looking, adorable kids set to tug-at-your-heartstrings music.
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Once again, we're hearing that some of the most vulnerable among us -- foster children taken from their homes because of abuse or neglect -- are being treated with "powerful, mind-altering drugs."

The latest news comes from several different sources. Last week, ABC News aired the results of its damning year-long examination on the topic. Then, the Government Accountability Office, Congress' nonpartisan investigative arm, released a report showing that foster kids in several states are medicated at several times the rate of their peers on Medicaid.

The GAO report also found that, contrary to medical guidelines, foster children were more likely to be prescribed five or more drugs at once, be treated with dosages exceeding the recommended maximum, and to receive medications when they were younger than a year old.

A Senate subcommittee held a hearing examining the GAO report -- the latest of several congressional hearings in recent years involving foster kids and medication. Separately, prominent academic researchers released a study showing that, even compared to children who qualified for Medicaid because of a disability or low income, foster kids are far more likely to receive multiple psychiatric drugs at once.

The reaction to these reports has been overwhelmingly negative. This is hardly surprising. It's an easy subject to line up against. I mean, how many people are going to argue that we should be, as an outraged blog on the website of the Minot, North Dakota, paper put it, "drugging foster kids into a stupor"?

The reality, though, is far more complicated than it appears in the political theater of a congressional hearing, or in television news shots of sad-looking, adorable kids set to tug-at-your-heartstrings music.

The GAO report, which advocates that the U.S. Department of Health and Human Services do more to help states monitor and oversee the treatment of foster children, is sober and nuanced. Its specific findings regarding infants, treatment with five or more medications, and maximum exceeded dosages are alarming. But few people will read the report itself, and it's too easy to elide its specific recommendations into an argument against treating foster children, or just kids in general, with psychotropic drugs.

Knowing that, I'd like to share the experience of a former foster child whom I interviewed in depth for a book on growing up on psychiatric meds.

When I first heard this young man's story, he seemed to me like a perfect poster child demonstrating the horrors of medicating foster kids. But the more I heard, the more it seemed that although he had good reason to resent medications, his case was complex and far from clear-cut.

Like the children briefly featured in ABC News' recent investigation, this young man has fared so well without meds that at first glance you, too, might conclude he never should have been put on drugs in the first place. Now in his mid-20s, he hasn't taken medication since he secretly quit his anti-psychotic drug partway through high school. He's in college and also works several jobs, including mentoring foster children. He recently married the love of his life.

He spent most of his childhood and adolescence in foster care. For a decade he took medication for ADHD and then for bipolar disorder, conditions he's convinced he doesn't have. An antipsychotic drug for bipolar disorder seems to have caused weight gain and diabetes that disappeared when he stopped taking it.

But listening carefully to him over the course of many months, I came to think that perhaps medication was not the patently absurd and unjustified measure it had initially seemed.

He was taken from his disabled mother at age five because she was unable to keep him from roaming the streets of a neighborhood with warring gangs. His father beat him and his mother. And though this young man did not want to discuss it publicly, he hinted to having experienced further traumas, both with his parents and in the foster system.

After foster care officials permanently revoked his parents' custody, he bounced through at least two dozen placements, at one point spending months in an inpatient psychiatric facility. He thinks his rebellious behavior, which included beating up other children and vandalizing foster homes, was a factor in the frequent relocations.

He wasn't just a menace to kids around him. Adults who cared for him feared he might hurt himself. His actions included climbing up on to the roof of the group home where he lived and threatening to jump.

Although adults in his life maintained his psychiatric problems left him out of control, he insisted to me that he the acting out was a deliberate bid for attention. He felt so alone and neglected that any attention from adults -- even in the form of punishment -- was better than none. And he had grown up in a family and a community where being tough was valued and necessary for self-protection.

All he wanted, he told me again and again, was a loving family he could trust unconditionally. He says he fared much better when for a couple of years he lived with such a family. And when that couple adopted other children instead of him, he was devastated. He overdosed on his medication in an attempt to "fix" himself. Yet, the more he misbehaved, the more he hurt his chances for adoption.

So should a child like this be medicated? I think it's very difficult to say. The GAO report makes the astute but often overlooked point that, despite the alarming statistics about foster children being medicated at several times the rate of their peers on Medicaid, it's impossible to judge the appropriateness of their treatment without examining each child's file for information on diagnoses, dosages and the many circumstantial factors doctors take into account when prescribing. These are, after all, severely traumatized children who suffer from mental illness at disproportionately high rates. Being shifted from one placement to another only destabilizes them further.

I can understand why the young man I interviewed and several of the children in the ABC News investigation think they never should have been treated with drugs. Already neglected and abused by their parents, many of them felt adrift and alone in the foster system. Medication must have seemed like further neglect. Instead of relationships with adults who would listen to them and care about them, it seemed, they were given pills to shut them up.

Medication, in other words, came to represent just one more instance of the world not doing right by them.

But I can also understand why doctors, case workers, teachers and others might have thought meds useful in this young man's case. Though he says the particular drugs he took never did anything for him except cause unpleasant side effects, that doesn't automatically mean it was crazy for doctors to try a pharmaceutical intervention. He was, by his own account, a disturbed and disturbing kid.

The devil is in the details -- what doses he took of what drugs, for how long and for what diagnoses and contextual reasons. He did not want to give me access to the records that contained these details. Without knowing this information, though, I don't think it's fair to hold him up as an unambiguous example of the dangers of prescribing medication to foster children.

Yet that's usually what happens all the time in the debate over medicating foster kids. We hear alarming statistics that seem to suggest "overmedication" and hear brief personal anecdotes that seem to suggest the horrors of life in a medicated haze but provide little or no contextual information.

I spent many, many hours interviewing this young man, but all I can say is that he was dealt a very bad hand, that he didn't receive the love and stability that children need to flourish. Medications were a band-aid on a gaping wound -- fundamentally inadequate, but not necessarily unjustified.

Journalist Judith Warner, in a recent column in Time, suggests that too often, when it comes to psychological care for foster children, band-aids are all we're willing to pay for. It's worth noting that this particular young man received a battery of supports -- case workers, psychologists, specialized schools, "therapeutic" foster placements and yes, medication. These supports simply don't seem to have been coordinated in a way that motivated him to improve his behavior, and, most importantly, allowed him to heal.

He badly wanted a family, but loving and willing adoptive families, especially for the most difficult children, are understandably in short supply.

It's easy to declare in the abstract that "too many" foster children are medicated. What, though, would be the right number? When you get into the nitty gritty of individual kids' experiences, you see how difficult it is to make a call about what should -- and, realistically, what could -- have been done.