Foster Youth meets Psychiatry: First Do No pHarm

When a foster youth encounters a psychiatrist, chances are high that s/he will get medicated.  Traumatized foster youth are often prescribed powerful psychotropics due to exhibiting a wide variety of “normal reactions to abnormal events”, such as despair, agitation, anxiety and self-harm. The practice has been well documented; foster children are prescribed psychotropics at a 2.7 to 4.5 times higher rate than non-foster youth[1].  The National Center for Youth Law aptly summarizes the problem as: too many (25% of foster youth medicated), too soon (300 children under the age of 5 in California are given psychotropics annually) too much (adult dosages) and for too long[2].  Many foster youth don’t even get placed on the category of medications that corresponds to their assigned diagnosis.  According to a recent analysis[3], 40% of foster children diagnosed with ADHD and disruptive behaviors were prescribed anti-psychotics.  Still others are medicated without even the pretense of treating a documented illness.  This pattern suggests that medications are being expressly used for behavioral control. Foster youth are being placed in chemical strait-jackets.  

In California, belated progress is being made in effort to curb the egregious over-medication and under-treatment of foster youth.  Several key pieces of legislation have been passed with widespread support[4].  An ongoing work group has been convened to develop data collection methods to identify who is prescribing what to whom, as well as implementing prior authorization and second opinion mechanisms.  Attention is also being focused on building up the trauma informed care capacity to ensure that foster youth are offered “1st line” psychosocial treatments and make medications the last resort.  Funding for public health nurses to monitor medicated foster children and youth for metabolic complications is also being requested.

But there is an unacknowledged conundrum waiting in the weeds. Work group participants are discussing ways to distinguish between trauma impacts and true “mental illness”, as if there is some way to sort through the many “symptoms” (trauma adaptations) and assign them to discrete categories of disease vs. distress.  The DSM5 largely ignores issues of causation and context. (Let’s stipulate that virtually all foster youth and children have some form of traumatic stress reactions.)  When viewed through the distorting prism of the DSM5, foster youths' many understandably disturbed behaviors are seen as pathological indicators of an incipient brain disease.  “Psychiatric Bible” thumpers cast an ever expanding net that entangles most foster youth experiencing problems in thinking, feeling and behaving – the kinds of problems that most of them have in spades.

Perceptions of anguished foster youth are so shaped by the dominant bio-reductionist disease model that some have suggested that perhaps foster youth suffer from co-existing disorders -- both trauma and a “co-occurring” brain disease. This seems to violate the Law of Parsimony – explaining things in the simplest way, while making the fewest possible assumptions.  For example, let’s say someone’s lip bleeds due to being punched in the mouth. From a biopsychiatry viewpoint, someone’s lip bleeds due to a genetically predisposed lip disease that was triggered when they got punched. Poor Occam would throw away his trusty razor.

Developing trauma-informed, first-line alternatives will be key to the efforts focused on curbing the high rates of psychotropic medications for foster youth and children. But it won’t be easy and it won’t be cheap. (Perhaps some of the $226 million that California spends annually on medicating foster youth can be redirected?)  American culture has a long standing love affair for no stress/no mess, technological solutions in the form of pills. Pills that can tamp down and suppress the howls of pain and anger brought on by chronic abuse and neglect. (“Zombify” in the words of many foster youth.)  The experience of trauma at early, vulnerable ages often results in grievous wounds that can take a life-time to heal. Dr. Bruce Perry, author and director of the ChildTrauma Academy, contends that most current treatments for these kinds of developmental traumas are inadequate, that much trauma-informed care is delivered for too short a time, at too low a frequency/”dosage”, and is misdirected at “too high” of a neurodevelopmental stage. Clearly much work remains.

It is unacceptable that after suffering so much from the collapse of their family and support systems, that foster youth and children are subjected to potential further abuse of misguided treatments that carry such high health risks and stigma. Understanding and compassion for “what happened” to foster youth, rather than “what’s wrong” with them is imperative.