During a recent hearing at the Capitol, State Auditor Elaine Howle revealed the findings on her department's audit regarding the prescribing and oversight of psychotropic medications to children in foster care.
“The state authorized medications in dosages that exceed what’s in the guidance – multiple meds – excessive meds – than the guidance. Key overarching issues,” Howle said.
Tisha Ortiz risked getting late to class to be at the hearing. She's studying criminal justice at California State University, East Bay. She sat among other former foster youth as she awaited her turn to testify.
“How is it my fault that I was abused? It's not,” Ortiz asked. “How is it my fault that I'm in a group home? It's not my fault. The foster care system is a pretty dark place.”
California has, according to the auditor, the highest population of foster youth in America. Senator Mike McGuire, who called for the audit and led the hearing, noted that in 2006 only one percent of foster kids were on psych meds. That number has increased to 1 in 8 children today, McGuire noted.
Often being the children of drug addicted parents, many foster children begin life at a disadvantage. Some of them are abused sexually, emotionally and physically and that’s how they end up in the hands of the state. For children like Ortiz, this life comes with increasing challenges. Ortiz said she suffered abuse at a group home.
"My mom had just passed away,” Ortiz said. “She (a staff member at the group home) told me if she ever caught me crying, I'd be in serious trouble. I would hide in the showers just to cry. One time she got upset that I was crying and pulled me to the side and said, ‘Stop it, no one cares. No one is going to have empathy or sympathy for you ever. Why do you even care that your mother passed away when you weren't even close.’”
Sometimes kids with behavioral problems, as many foster kids show, get into the mental health system, where they end up on prescription drugs that many say have no place in the body of a child.
Dr. Stuart Bair has worked with children in foster care for decades and has observed doctors resort to pills over therapy.
“It's an easy fix or at least a superficial easy fix for a lot of systems, and a lot of doctors say, ‘Okay, here's the medication,’” Bair said. “’It will shut the kid up,' – very, very few of these kids have psychotic disorders for which these medications are clearly indicated.’”
Ortiz’s case is not rare. According to Howle’s report, 12 percent of children in foster care are taking psychotropic meds, including antidepressants, antipsychotics and mood stabilizers, among others.
When children under the age of 5 are excluded, the rate blows up, said Bill Grimm, a senior attorney at the National Center for Youth Law.
"Then you have a problem of about 25 percent or higher of every child in foster care between 6 and 17 being on one or more psychotropic medications, and that's a huge problem,” Grimm said. “Then when you look at the types of medications knowing that, at least our data seems to suggest, that half of those children are on antipsychotic medications that are only FDA-approved for a very, very limited diagnosis.”
“The audit concludes that the state and its counties have failed to adequately oversee the prescribing of these medications,” Howle said.
I asked Howle about those findings and she told me "we found that these children are receiving medications in excess of the dosages required or recommended in guidance.”
“The prescribing was a problem and certainly the follow-up,” Howle said. “And then the other piece was in conjunction with receiving a medication like this, a child should be receiving mental health services, counseling services, and we didn’t see evidence of that happening for many of these children, so they were essentially being given medications, not being seen frequently enough and then not being provided the health services they need.”
The audit found that in as many as 65 percent of cases, children are getting the meds without parental, guardian or court authorization, which, according to Grimm, is illegal.
“In California, before a prisoner – before somebody convicted of a felony, somebody, in fact, who might have victimized and sexually molested a child in foster care – before that prisoner can be administered a psychotropic med against their will, we have a much more rigid process in place,” Grimm said. “Our prisoners are entitled to more protection of their rights than our children in foster care who'd done nothing wrong, nothing that would allow them to be punished in any way.”
Ortiz said she often complained about the side effects of her medication. "They made me severely disabled. I couldn't wake up without wanting to go back to sleep,” she said. “I couldn't function on those medications. Even with just one medication, all I wanted to do was sleep all day.
“One time when I was pretty drugged up, I couldn't wake up in the morning, I was feeling very sick,” she added. “I wanted to puke, and a staff member was upset that I wasn't waking up for school and decided to throw me and my bed against the wall because I wasn't waking up to go to school.”
“The antipsychotics are clearly the biggest problem at this point,” Bair said. “Medication's side effects typically include serious sedation, movement disorders, and sometimes irreversible movement disorders. Sometimes where you just feel like you can't sit still and you're jumping around, which then looks as if you're more agitated when in fact it's a side effect of medication."
I asked if this could possibly motivate another prescription. "Exactly. Exactly,” Bair said. “Then there are the long-term metabolic problems of increased risk of diabetes and obesity.”
Ortiz said she went from 175 to 225 pounds while on the meds.
“I still sometimes get the facial tics. I'll feel them; they're kind of embarrassing, especially around the eyes. I'll feel them mostly around the eyes, I'll get the facial tics. Definitely the heart problem I still suffer from, it's permanent now,” she said. “The weight gain, I've been fluctuating with weight. It wasn't until recently, like the last six months, I completely came off medications, because before it was really hard to come off all those medications."
Ortiz decided to share her medical records with me. On her health and education passport, I noticed that at the age of 15, she was given Lithium, usually prescribed for bipolar disorder, which she wasn't diagnosed with. Simultaneously she was prescribed an antidepressant named Trazodone.
I am far from an expert on medicine, but a simple Google search will show this drug has a major interaction with lithium. A drugs.com warning reads “The risk of interaction might outweigh the benefits.”
Ortiz was also on Geodon, a powerful antipsychotic to treat schizophrenia and bipolar disorder; none of these diagnoses appear on her records. Among its long list of side effects, according to the National Center for Biotechnology Information, the drug may cause heart rhythm problems, a life-threatening neurological disorder, serious skin reactions, twitching, uncontrollable muscle movements, tiredness, sleepiness, increased hunger, thirst, weight gain and on and on.
Dr. Bair described it as "trying to think through glue, so when you get these medications, your brain is fogged up and the things that kids need to do – they need to get educated, they need to learn how to develop peer relations."
Bair thinks these side effects could significantly inhibit those processes.
"We know things are not going well, so you have a kid who has essentially pharmacologically induced lack of development, immaturity,” Bair said. “And you also have a young person who may be 20, 30, 50 pounds overweight who wasn't able to learn anything in school because he or she was dead on her feet most of the time, doesn't know how to establish age-appropriate relationships either with his or her peers or with the adult world in general. It's not fair."
Ortiz was also placed on Abilify, with its own long list of side effects, including specific effects for teenagers like increased mental and emotional problems and thoughts of suicide.
I looked up her doctor’s name on the ProPublica Dollars for Doctors database, showing how much money doctors got from pharmaceutical companies, and just within a year of the study, her doctor had received $90 dollars in meals. Another doctor who switched her to a new antipsychotic, after she landed in the hospital likely from the side effects, got $168 dollars in food and beverage from the producers of this new medication.
It doesn’t sound like a lot of money but research shows even a little incentive goes a long way. “Doctors who receive payments from the medical industry do indeed tend to prescribe drugs differently than their colleagues who don’t," according to the ProPublica study.
It's that simple.
“What happened a number of years ago was that there was move afoot to make doctors think that there was bipolar disorder all over the place in kids,” Bair said. “If you have bipolar disorder, it's kind of a straight shot antipsychotic. The pharmaceutical companies were really big on this and said ‘let's increase our market by having an entirely new patient population that is under 18.’”
And that kind of medication isn’t cheap.
“Out of the 12 most costly drugs nationwide, three of the 12 were antipsychotic meds,” Bair said. “That is one of the highest group of classes of drugs that are given to children in foster care. This is no doubt that these drugs are some of the most costly that are handed out to patients whose care is paid for by Medicaid. We don't even know how much money in California is spent on alternatives to medication."
What we do know, thanks to a Mercury News study, is that over a decade, the state spent more than 226 million in taxpayer dollars on psych meds for foster children.
"These are human beings. What we know is foster youth already have challenges related to their long-term success of their life,” McGuire said. “We are the guardians. The state of California are the guardians of these youth and we failed them. It's unacceptable."
McGuire’s bill seeking to increase doctor accountability was recently signed by Governor Brown.
“It would confidentially turn over the medical records and prescription rates of California's foster youth to the Medical Board,” McGuire said. “The Medical Board would then be able to confidentially investigate serial over-prescribers via the medical and prescription records of foster youth. In addition, the bill would allow the attorney general to open up a case to go after a serial over-prescriber."
I met with Jennifer Kent, Director of the Department of Health Care Services, which oversees the medical needs of children in foster care. She said her department agrees with the audit's findings.
"I think, like all audits, it always provides room for improvement, points out places where we can make changes in our system to either deliver services in a better way or more efficient way,” Kent said. "In this particular audit, we agree with the findings, and so we’ve already made most of the changes. There are some that are still in process that we are making."
Kent acknowledged that this population needs more scrutiny and that her department welcomes the opportunity to work with the Department of Social Services to gradually fix the issues.