The Press Democrat
When she was 9 years old, Angelica De La Torre saw her mother fall from her pedestal of strength and virtue into a place torn apart by methamphetamine addiction. Unable to deal with the loss of the single most important person in her life, De La Torre herself fell into depression and helplessness.
At 13, De La Torre was taken from a broken home by the Sonoma County welfare system. Soon after that she was prescribed Zoloft and Prozac to help her deal with her depression, anger and sorrow. Instead, she said she used those psychotropic pills to try to kill herself.
“That was my preferred way of trying to commit suicide,” said De La Torre, now 21. “I took the whole bottle because I didn’t want to deal with something being wrong with me, like I was not capable of living a normal life. ... I didn’t want to feel like I couldn’t be happy without having to take something.”
De La Torre, now a student at Santa Rosa Junior College with an eye on a career in naturopathic medicine, continued to take psychotropic medications after entering the local foster care system. She said she laments never being given an alternative to the drugs, which she said did nothing to make her feel better.
“If anything, it made me feel like suicide was a better option,” she said.
De La Torre said she believes she was inappropriately prescribed psychotropic medications as a means of controlling behavioral and emotional issues that should have been dealt with in other ways.
That belief is at the core of a major controversy facing the state’s foster care system, where more than 26 percent of all foster children between the ages of 11 and 17 were prescribed psychotropic medications last year. About half of those kids were on antipsychotic drugs, according to the latest state figures.
Such alarming rates have drawn the attention of investigators for the California Medical Board, who are trying to determine if physicians may be inappropriately prescribing the medications. The board’s review comes as county social welfare departments across the state are also trying to grapple with any potential problems.
Sonoma County is at the top of the list of counties with the highest rates of psychotropic prescriptions among foster youth. Nearly 23 percent of all local foster kids were on the drugs during the 12-month period that ended last June, nearly double the 11.8 percent rate for all 79,166 children who were in the state’s foster care system.
“You have to ask: What are doctors in Sonoma County learning about how to prescribe?” said Carmen Balber, executive director for Consumer Watchdog, a consumer advocacy group that in recent years has called for tougher monitoring of medication practices in the foster care system.
Some children in the foster system warrant a psychotropic prescription, Balber said. But the current levels are “disturbing,” she said, particularly since the young people involved have fewer advocates than most other kids.
“The big concern is that these medications are being used to control behavior instead of legitimate mental illness,” Balber said. “It is impossible that one quarter of kids in the foster system have such severe mental illness to justify these medications.”
Last year, Gov. Jerry Brown signed a set of bills aimed at curbing the overuse of psychotropic medications in the state’s foster care system. The bills increased the responsibility of the juvenile court system, the state Department of Social Services, public health nurses and others to monitor the use of psychotropic medications on an individual and statewide level. But foster youth advocates say the bills omitted one key player: doctors who prescribe the medications.
This year, state Sen. Mike McGuire, D-Healdsburg, has sponsored a bill that would authorize the California Medical Board to collect confidential information about psychotropic medications prescribed to foster youth. The legislation, SB 1174, which is scheduled to be considered by the Senate Appropriations Committee on Monday, would allow the medical board to investigate possible cases where a physician is overprescribing or inappropriately prescribing psychotropic drugs.
McGuire said the California foster care system is overusing psychotropic medications, which may prove harmful over time to the children placed under system care.
The drugs are necessary for some youths who have experienced “incredible trauma,” he said, but are in many cases being used to control their behavior and substituted for the therapy they need.
“We’re talking about people’s lives,” McGuire said. “California has known for a decade that psychotropic medications and antipsychotics have been overprescribed and we haven’t done a damn thing about it.”
Medical researchers have shown that prolonged use of antipsychotics can cause lifelong harm, contributing to obesity, diabetes, brain damage, organ failure or even death, McGuire noted.
Most of the physicians who care for foster children are doing an appropriate job, he said. His bill is aimed at “a small percentage of prescribers” who are engaging in potential violations of state law, he said.
Anna Johnson, policy analyst for the National Center for Youth Law, which helped craft both McGuire’s legislation and last year’s bills, said SB 1174 helps bridge the gap between county welfare and mental health departments. Too often, she said, county welfare systems contract with mental health department psychiatrists to do little more than prescribe psychotropic drugs.
“That’s problematic because these medications are not supposed to be the first and only treatment that a child receives,” Johnson said.
Johnson said psychotropic drugs, when prescribed inappropriately, such as in the wrong dose, can often blunt a child’s development. Some of the drugs block dopamine receptors that would allow a child to feel joy or form attachments.
“Some of the more positive sensations are dulled by the drug, or they might be inhibited in some way,” she said. “Some studies show that kids become like zombies. ... They’re not able to react in the moment or be themselves.”
She said some young people, when prescribed doses that are too high, will lose trust in their caregivers or providers because of the extreme negative side effects, which include heart disease, diabetes, weight gain, ticks and tremors, an increase in suicidal thoughts and even sudden death in some youth, especially when these medications are mixed with other recreational drugs like alcohol or marijuana.
McGuire’s bill would provide additional information that the state medical board says it needs to complete its review of prescribing patterns statewide and identify the physicians who may warrant additional investigation. It includes the diagnosis associated with the medication, dosage and weight of the youth, said Cassandra Hockenson, a medical board spokeswoman.
“Keep in mind, this is necessary for us to determine who potentially is prescribing inappropriately,” she said.
Anthony Northern was about 14 years old when a conflict with his brother landed him in Juvenile Hall.
He was removed from his home and sent to a local group home, where he was put on several medications, including Seroquel, which is often used to treat schizophrenia, bipolar disorder and depression. Northern, now 21, said nearly every other youth in the home on medication for mental health issues was required to take Seroquel.
“I floated around like a zombie, half dazed,” he said. “I was really happy to get off the medication, but you have to wean off of it; otherwise, it can have really adverse side effects.”
Northern said he now only takes medications he’s requested himself, including trazodone to help him sleep and Concerta for his attention deficit hyperactivity, or ADHD. He has been attending Lytle’s Redwood Empire Beauty College in Santa Rosa and has plans to one day live and work in San Francisco or Los Angeles.
“I’m no longer taking an antipsychotic or mood stabilizer. I’m no longer on depression medication, because I don’t need it,” he said. “Maybe at that time, I may have actually needed those meds, but there’s honestly a lot of better ways of dealing with the problems I was facing than handing me meds.”
Northern said that when he was in “a zombie-like state” he wasn’t actually dealing with the emotions that were the source of his behavior.
“It was almost like I was mood-stabilizing and sedating them, so I didn’t have to feel any of those things,” he said. “One of the ways that you ever really get over anything — any sort of emotion, anger, sadness — is to process it, hold on to the feelings, understand what they’re doing to you and let it go.”
The state medical board received 8,267 complaints of over-prescribed medications for people of all ages in the fiscal year 2014-15 and opened 1,381 cases for investigation, according to McGuire. As a result, 471 cases were referred to the Attorney General’s office for formal proceedings and 47 medical professionals were disciplined for inappropriate prescribing practices.
Not one complaint was filed on behalf of a foster child, McGuire said, because the children lack advocates.
“No one is standing up for these youth,” McGuire said, noting that the state is the legal guardian for foster children. “We aren’t doing our job.”
Representatives from the medical field have acknowledged a need for reforming foster care.
In April 11 testimony on McGuire’s bill before the state Senate committee overseeing business, professions and economic development, an official with the influential California Medical Association said “real structural problems (exist) within the foster youth system.”
But the association, which represents 41,000 physicians, doesn’t think the bill aimed at disciplining some doctors will improve the health outcomes for foster youth, said Stuart Thompson, an attorney for the group.
Medical board investigations typically go on for one to three years, which means that any corrective action would come “years after a child had received medication they shouldn’t have gotten,” Thompson said.
The physicians group agrees with the idea of providing foster youth with “therapeutic treatments that aren’t based on drugs,” he said. Rather than seeking penalties against some professionals, Thompson said there should be “some sort of educational outreach” to ensure that proper prescribing standards are followed.
Nick Honey, Sonoma County’s director of Family, Youth and Children’ Services, said the county’s high rates of prescribing drugs “need to be addressed.” However, he said they are not an indictment of the local foster care system and its community partners, most of whom, he said, are deeply concerned about children.
“These patterns are not an indicator that people don’t care about the children that they’re serving,” he said. “We do care about children in foster care and we want to make sure that they get the best care possible.”
Honey said some children in the foster system have serious mental health issues that need to be treated, including with drugs. But if the rate of medication is too high or not appropriate, he pledged that county would seek to correct it.
Honey said his department has been analyzing the county’s high rates of medication among foster youth since 2013, when the department became aware of the rates while working on a “system improvement plan.”
At that time, the county determined that 24.4 percent of foster youth in Sonoma County were authorized for psychotropic medications, compared to the state average of 13.4 percent. The analysis covered the period between 2010 and 2012.
The majority of local foster children who are prescribed psychotropic medications live in group homes. A county-provided breakdown dating to 2012 showed 77 foster children — comprising 59 percent of those who were prescribed psychotropic drugs — were placed in group homes. Fifteen percent were in foster family agency homes and 4 percent were at the Valley of the Moon Children’s Home. The remainder were in other types of homes.
Honey said his department has been trying to reduce the number of placements in group homes, a trend occurring across the state. Last August, there were 53 foster children in group homes, down from 114 in August 2010. A similar effort is underway at the county probation department, which currently oversees 30 foster children, all of whom live in a group home setting. The county is trying to determine if its rates of psychotropic drug prescriptions are accurate or representative of a more troubled youth population, Honey said.
“We’re trying to determine whether it’s overprescribing or whether it’s a data entry issue,” he said.
Honey said that Sonoma County often gets foster youth from surrounding counties who have experienced greater degrees of abuse and neglect, some of whom have just been released from an inpatient psychiatric hospital.
“It’s not necessarily a representative sample,” he said.
One of the measures the county put in place last year is the use of a “second opinion psychiatrist” who reviews the court document that must be signed by a judge to approve the use of psychotropic medications for foster youth. That form, known as a JV 220, and its attachments list information which a small team of pediatric psychiatrists use to determine if the prescription is appropriate.
The information includes details about the child, including name, age, residence, prescribed medications, the name and specialty of the prescribing physician, the child’s symptoms, mental health diagnoses and alternative therapeutic services.
Dr. Michael Kozart, medical director for the county’s behavioral health division, said the “second opinion” psychiatry team began reviewing the forms last May. The impact of that oversight has yet to appear in state data describing county prescribing patterns.
“It’s a bit early. In a sense we haven’t actually got data from this year to compare,” he said. “Our hope is that we’re providing greater oversight and a second opinion to guard against excessive prescribing of psychotropic medication.”
Kozart said he believes McGuire’s bill is motivated by a strong desire to protect children from inappropriate prescribing of these medications. He also believes that most behavioral health professionals are constantly reviewing their practices to ensure that they adhere to the most recent guidelines and evidence-based practices.
“Again, my only hope is that we find a way to implement these laws, but not at a price of instilling a culture of fear that could negatively impact our overall care system,” he said.
Amber Twitchell, program director of VOICES, a local center for young people who are transitioning out of the foster system, said greater access to mental health services is needed for all youth, but especially for neglected foster youth.
“When we try to get a young person mental health treatment, it’s not easy,” she said. “They’ll get sent to a community clinic ... medication becomes an easy crutch to lean on.”
Twitchell said more alternatives to medication, such as physical exercise, social and recreational activities and permanent connection to supportive adults, could alleviate some of the behavioral and emotional issues that are too often masked by medication.
“Children’s mental health in general and the mental health of foster youth has not traditionally been something the community has focused on,” she said.