Doped in Foster Care: Improper Drugging of Florida Foster Children Still Rampant Five Years After Tragedy

Florida Department of Children and Families Records Reveal No Lessons Learned from 7-Year-Old Gabriel Myers' Death



On April 16, 2009, 7-year-old Gabriel Myers is believed to have hanged himself in the shower of his Margate foster home. The toxicology report came back positive for amphetamine, fluoxetine, and olanzapine. A coroner's review of medical records indicated that psychiatrist Dr. Sohail Punjwani had prescribed young Gabriel 50 mg of Vyvanse (lisdexamfetamine) daily, and 25 mg of Symbyax (fluoxetine and olanzapine) three times per day. Approved for the treatment of Attention Deficit/Hyperactivity Disorder (ADHD), Vyvanse is an amphetamine class stimulant, which according to the drug's label, "at recommended doses, may cause psychotic or manic symptoms, e.g. hallucinations, delusional thinking, or mania in children and adolescents without a prior history of psychotic illness or mania." Symbyax is a combination of two other powerful psychotropic drugs, the antipsychotic Zyprexa (olanzapine) and the antidepressant Prozac (fluoxetine).


Broward Deputy Chief Medical Examiner Dr. Stephen Cina noted in the autopsy report, "Olanzapine, either alone or in combination with fluoxetine, is not [approved for use in children]." Indeed, the drug's black box warning – the strongest possible – states emphatically, "Symbyax is not approved for use in children less than 10 years of age."


Reiterating another black box warning about Symbyax, Dr. Cina further noted in the report, "Fluoxetine and olanzapine can increase the risk of suicidal ideation in children taking this drug." Despite concluding that Gabriel's actions led to his demise, Dr. Cina deemed the manner of death to be undetermined, not suicide. Dr. Cina wrote, "It is unclear whether these drugs contributed to this fatality or not."


After conducting an investigation into his clinical trial practices, the Food and Drug Administration (FDA) issued a warning letter to Dr. Punjwani, citing violations including failure to protect the rights, safety and welfare of human test subjects; doses exceeding protocol-specified limits; and failure to follow clinical trial plans. 


While questions about Gabriel's death persist even to this day, what is indisputable is that his passing sent shock waves through the Department of Children and Families (DCF), prompting a comprehensive review of how psychotropic medications are administered to foster children in Florida. Commissioned to study the problem and make recommendations, the Gabriel Myers Work Group (GMWG) held public hearings and questioned DCF employees about their practices with regard to psychotropic drugs. The group's findings and recommendations sparked changes in state law, administrative rules, and departmental operating procedures.


Despite official changes in law, policy and procedures, department records reveal that it has been business as usual inside DCF for the last five years, with not much changing in practice with respect to the administration of psychotropic medications to foster children since Gabriel Myers' death.


Chemical Restraint: Without Noted Diagnosis, Foster Children Drugged to Control Behavior

Florida law requires that doctors prescribing psychotropic medications to children in foster care complete a medical report, which must include the child's diagnosis. Florida administrative code further requires case managers and child protective investigators to enter all details and updates about prescribed psychotropic medications in the Florida Safe Families Network (FSFN), DCF's central tracking system, within three business days of the action.


However, DCF records indicate that over the last five years psychotropic medications were prescribed 80,276 times to 25,215 foster children without a psychiatric diagnosis recorded in FSFN.  These lapses in diagnosis annotation in FSFN are contrasted by 39,019 psychotropic medications prescribed to 3,806 foster children during the same period where at least one psychiatric diagnosis was noted in FSFN


So many psychotropic medications being prescribed without a noted diagnosis raises concerns that Florida foster children are being medicated to manage their behavior, rather than to treat a bona fide mental illness.


In recent testimony to the U.S. House Ways and Means Subcommittee on Human Resources, celebrity psychologist Dr. Phil McGraw alerted Congress to the practice of drugging foster children without a diagnosed psychiatric condition: "As I said, and cannot emphasize to you enough, some of these children have no mental illness or disorder whatsoever, yet they are medicated." 


In Florida, chemical restraint is defined as the use of a medication as a restraint to control behavior that is not an accepted treatment for the person's medical or psychiatric condition. Florida administrative code strictly prohibits the administration of medication to foster children for the sole purpose of chemical restraint. 


Teenage Wasteland: Chemical Management of "Adolescence Disorder"


According to the Office of Child Welfare's weekly Meds Report, nearly one-third of all teenagers in foster care are taking one or more psychotropic medications, suggesting that adolescence is one of the most under-diagnosed or under-noted "mental conditions" in FSFN.  As reported by DCF, just 12 percent of foster children of all ages are currently on psychotropic medications, but that rate increases considerably to 30 percent for teenagers aged 13 to 17 in foster care.


Many parents would agree that kids' behavior can be more difficult to manage once they hit puberty. DCF's answer to the age-old dilemma: drug them. 


"These children need to be treasured and protected, and to be given wrap-around loving care," said Dr. Peter Breggin, a psychiatrist who has testified to Congress about the risks of psychotropic drugs and has authored over twenty books, including his latest Psychiatric Drug Withdrawal: A Guide for Prescribers, Therapists, Patients and Their Families. "They do not need psychiatric drug interventions, which inflict more neglect and abuse by suppressing their mental functions in order to make them more manageable."


DCF's War on Boys: Medicating "Y Chromosome Disorder"


From Left to Right: Pasco and Citrus County Child Protective Investigators notably lacking Y chromosomes


While teenagers in Florida foster care are two and a half times more likely to be prescribed psychotropic medications than younger foster children, there is another "mental illness" besides adolescence that puts foster children in the Sunshine State at even greater risk of being chemically restrained.  Roughly half of all foster children, it seems, entered life with a "birth defect", namely with a Y chromosome.


Considering that the vast majority of case managers and child protective investigators are themselves lacking such a chromosome, it is perhaps not surprising that, according to the weekly Meds Report, 63 percent of foster children taking one or more psychotropic medications are in fact boys.

         

"More boys than girls are given psychiatric drugs because boys can be harder to dominate and to control in our society," said Dr. Breggin. "Also, psychiatry and society in general have set standards for boys which suppress normal boyhood behavior. The greater drugging of boys is one more confirmation that it’s all about control."


"We are pathologizing boyhood," psychiatrist Dr. Ned Hallowell recently told men's magazine Esquire for an article entitled The Drugging of the American Boy.


UCLA geneticist Susan Smalley, Ph.D., who also Co-Chairs the feminist group Equality Now, began research efforts over a decade ago to scan sex chromosomes for clues that could link ADHD genetically to boys. No genetic ADHD link to gender has been identified after years of costly research. 


That the foster care death igniting the firestorm surrounding DCF five years ago involved a boy who was prescribed psychotropic medications is not statistically anomalous. In addition to being prescribed psychotropic medications in Florida foster care at a much higher rate than girls, boys account for nearly three-quarters of the hundreds of pediatric deaths reported to the FDA involving stimulant medications used to treat ADHD.


Comprising nearly two-thirds of the foster children in Florida taking psychotropic medications, boys are disproportionately at risk for serious adverse effects from the medications.


Risky Business: Psychotropic Drugs Prescribed for Unapproved Uses


While many foster children in Florida have been prescribed psychotropic medications over the last five years without a psychiatric diagnosis noted in FSFN, still others do have a psychiatric diagnosis noted in FSFN, but were prescribed psychotropic medications that are not approved to treat their diagnosed condition.


For instance, many foster children with only a diagnosis of ADHD noted in FSFN have been treated with antipsychotics, which are not approved for the treatment of ADHD.  ADHD-diagnosed foster children with no comorbid psychiatric diagnosis noted in FSFN have been prescribed the antipsychotics Abilify (aripiprazole), Clozaril (clozapine), Geodon (ziprasidone), Haldol (haloperidol), Risperdal (risperidone), Seroquel (quetiapine), Thorazine (chlorpromazine), and Zyprexa (olanzapine).


In a recent study published in the Journal of Child and Adolescent Psychopharmacology, researchers found that nearly one-third of foster children aged 2 to 17 who were diagnosed with ADHD were being treated with antipsychotics such as aripiprazole, quetiapine, and risperidone.


"This study adds critical hard data to our understanding of a persistent and unacceptable trend in pediatric psychiatry," said psychiatrist Dr. Harold S. Koplewicz, the journal's editor-in-chief, in a press release. "Our poorest, most vulnerable children, lacking access to evidence-based care, are receiving potentially harmful treatment with little oversight."


According to DCF records, the antipsychotic drugs aripiprazole, olanzapine, quetiapine, and risperidone were prescribed 13,626 times to 6,837 foster children over the last five years with no diagnosis noted in FSFN.


"The use of antipsychotic drugs such as Zyprexa, Risperdal, Seroquel and Abilify to control the behavior of children displays a callous disregard for their well-being," said Dr. Breggin. "These drugs produce widespread neurological damage, including shrinkage of the brain, as well as a metabolic syndrome that includes obesity, increased cholesterol and sugar levels in the blood, hypertension, diabetes, and cardiac arrhythmias, which can be acutely fatal and also shorten the life span."


In addition to being prescribed antipsychotics, many foster children with only a diagnosis of ADHD noted in FSFN have been treated with antidepressants, which are not approved for the treatment of ADHD. ADHD-diagnosed foster children with no comorbid psychiatric diagnosis noted in FSFN have been prescribed the antidepressants Celexa (citalopram), Elavil (amitriptyline), Lexapro (escitalopram), Oleptro (trazodone), Paxil (paroxetine), Prozac (fluoxetine), Remeron (mirtazapine), Tofranil (imipramine), Wellbutrin (bupropion) and Zoloft (sertraline).


For the entire class of drugs known as Selective Serotonin Reuptake Inhibitors (SSRI), the FDA found that, compared to placebo, these antidepressants increase the risk of suicidal thinking in children, adolescents and adults under the age of twenty-four, and required manufacturers to issue a black box warning. While the FDA warned about the link between the latest generation of antidepressants and suicidal thinking, it has since come to light that researchers conducting an influential SSRI study downplayed the fact that 17 out of 18 suicide attempts committed during the study were done by subjects exposed to the SSRI. The SSRI in the study? Fluoxetine, which as noted was one of the psychotropic drugs Gabriel Myers was taking at the time of his self-inflicted death.


Foster children with only a diagnosis of ADHD noted in FSFN were also treated with other psychotropic drugs not approved to treat ADHD, such as the mood stabilizers Depakote (valproic acid), Lamictal (lamotrigine), Tegretol (levetiracetam), and Trileptal (oxcarbazepine); as well as the antianxiety drugs Ativan (lorazepam), Buspar (buspirone), and Klonopin (clonazepam).


Dr. Phil warned Congress that "foster children may be properly diagnosed but improperly treated with medications with no scientific support for use with that particular disorder. This is especially disturbing when we have non-medication treatment techniques that are proven effective, and very importantly, do not have the long list of medication side effects."


Russian Roulette: Foster Children Still Prescribed Untested Multi-Drug Cocktails


As shocking as it may seem that five years after the death of Gabriel Myers many foster children in Florida continue to be prescribed psychotropic medications for unapproved uses, or even for no noted diagnosis in FSFN; perhaps the most troubling aspect of the psychotropic drugging of foster children in Florida revealed through DCF records is the continued prevalence of multiple drug regimens, often referred to as cocktails.


Like Gabriel Myers who was prescribed a cocktail of a mania and psychosis-inducing stimulant, a suicidal thought-provoking antidepressant, and an antipsychotic unapproved for use in children; hundreds of foster children in Florida have been prescribed untested psychotropic cocktails which can often include combinations of stimulants, antidepressants, antipsychotics, mood stabilizers and antianxiety medications.


Dr. Phil testified to Congress about the perils of prescribing multiple drug regimens to foster children: "The risks of this polypharmacy, the use of multiple drugs from multiple categories, is unfathomable. Research does not support this practice and drug-to-drug interactions potentially create more problems than they solve."


Likewise, Dr. Breggin cautioned: "Whenever you put children on multiple psychiatric drugs you are creating an experiment that is doomed to do more harm than good, and to impair the child's growth and development. There are no studies of giving multiple psychiatric drugs to children, because such studies would be unethical and result in a great deal of harm."


"We need to stop experimenting on America's children," he added.


One-Way Ticket: Aging Out Often the Only Escape for Medicated Foster Children


Florida administrative code requires prescribers to develop a plan to reduce and/or eliminate ongoing administration of psychotropic medications to foster children. Despite the existence of this requirement since March 2010, DCF only began tracking the end date of psychiatric diagnoses in FSFN beginning in November 2013.


Among the 28,909 foster children prescribed one or more psychotropic medications in the last five years, only 3,806 even had a psychiatric diagnosis noted in FSFN, and of those only eight had an end date listed for their diagnosis.


Moreover, hundreds of foster children with only a temporary diagnosis of Adjustment Disorder, a condition which according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) is only valid for up to six months after the termination of the stressor or its consequences, were prescribed psychotropic medications indefinitely.


In many cases, foster children with only a diagnosis of Adjustment Disorder noted in FSFN were prescribed stimulants, antipsychotics, and antidepressants for years on end.


Dr. Breggin commented: "That many children are prescribed psychiatric drugs for the diagnosis of Adjustment Disorder indicates the cavalier attitude of prescribers since no psychiatric drugs are approved for the treatment of Adjustment Disorders, and since by definition Adjustment Disorders are time-limited while the medications go on interminably."


While Adjustment Disorder illustrates how a temporary diagnosis can easily translate into permanent psychotropic drugging, many more foster children have been prescribed psychotropic medications for extended periods who have no psychiatric diagnosis noted in FSFN, let alone a temporary one.


Drugged Illegally: Without Informed Parental Consent or Court Order


In its findings, the GMWG cited failures of responsible parties to obtain either informed parental consent or judicial authorization for the administration of psychotropic medications to foster children. Since before the death of Gabriel Myers, Florida law has required that DCF obtain either informed parental consent or a court order prior to administering psychotropic medications to children in its care. A temporary exception is made for emergencies, but in such cases, if parental or guardian consent cannot be obtained, DCF must apply to the court for authorization within three days.


DCF records indicate that in the last five years 15,251 psychotropic medications were prescribed to 8,201 foster children without either parental or guardian consent, or court authorization noted in FSFN.


Every class of psychotropic medications has been prescribed to foster children without parental consent or a court order, including stimulants, antipsychotics, antidepressants, mood stabilizers and antianxiety drugs. In almost every case where parental consent or a court order was not noted in FSFN, there was no psychiatric diagnosis noted in FSFN either.


"Foster children are particularly vulnerable to institutional abuse," noted Dr. Breggin. "They especially need the law to be strictly followed in regard to requirements for parental or court-ordered consent to psychiatric medication."


Poor Record-Keeping Means Poor Monitoring of Psychotropic Medications


The GMWG remarked in 2009: "FSFN data are frequently incomplete and inaccurate." One of the major reasons identified for the lapse in record-keeping: "Case managers are required to enter medical information into FSFN, yet often do not understand the information and cannot verify its accuracy."


There is no doubt that record-keeping shortcomings persist to this day when tens of thousands of foster children prescribed psychotropic medications over the last five years do not even have a diagnosis noted in FSFN.


A December 8, 2011 memo from Christie Ferris, then Director of Child Welfare, sent to Regional Directors stated, “A recent review of the psychotropic medication data in FSFN found that case managers are not appropriately documenting this information in FSFN.”


Another memo sent to Regional Directors just three months later by Patricia Armstrong, then Director of Child Welfare, stated, “It is critical that information regarding the use of psychotropic medication is current and accurate as part of each child's medical history in FSFN."


"Although we have improved," Armstrong wrote, "more work remains."


While more work remains, Armstrong did not. Andrea Tulloch replaced her as Director of Child Welfare. Despite frequent rotation at the top, the message does not seem to be filtering down to the Regional Directors, or ultimately to the case workers and child protective investigators.


The GMWG also noted in 2009: "The list of psychotropic medications in FSFN, while extensive, does not include all drugs used for such purposes." According to a DCF document intended to dispel confusion among physicians regarding the use of psychotropic medications, Vyvanse and Symbyax -- the two drugs Gabriel Myers was prescribed at the time of his death -- were not included in the drop-down menu of FSFN back in 2009. Incredibly, this still appears to be the case as neither Vyvanse nor Symbyax show up as having been prescribed during the last five years.


According to an Express Scripts report, Vyvanse or lisdexamfetamine had the third highest share of the ADHD drug market in 2012, making it highly unlikely that the drug has not been prescribed to a single foster child in Florida for half of a decade. While fluoxetine and olanzapine appear separately in the FSFN drop-down, when combined in one capsule the two are referred to as Symbyax, which is also notably absent from FSFN.


That five years later the two drugs which the medical examiner could not rule out as possibly contributing to Gabriel Myers' death are not properly recorded in FSFN is almost inconceivable. But perhaps a more important question than how this could be, if it can be inferred from market data that these drugs have indeed been prescribed to foster children over the last five years, is where did these prescriptions go -- a blackhole?


The psychotropic drugs that are not included by name in the drop-down in FSFN are listed as "Other". According to DCF records, 24,850 psychotropic medications designated as "Other" have been prescribed to 6,421 foster children over the last five years. 


If drugs cannot be tracked by name in FSFN, then how could DCF quickly determine who to contact in the event of a national recall? How can DCF track whether contraindicated drugs are being prescribed concomitantly? How can DCF track which psychotropic drugs are causing serious adverse effects?     


The simple answer is they cannot, for that which is not named cannot be monitored in any meaningful way. While much of the focus has rightly been on case manager and child protective investigator data entry, or lack thereof, the GMWG also recommended back in 2009 that "[DCF] should continue refinements to [FSFN] to increase its 'user friendliness' and to reduce the number of free text and 'other' entries." Yet the problem persists five years later.


Unfortunately, the problems created by the "Other" classification do not end there. According to departmental data entry guidelines, "A general rule of thumb at present is, if a medication is listed in the FSFN dropdown box, OR if a treatment plan states a medication is for psychiatric or psychotherapeutic purposes, then it is considered psychotropic."


That means potentially tens of thousands of prescriptions for psychotropic medications with a classification of "Other" or that were ostensibly prescribed for medical purposes could be improperly excluded from the count of psychotropic medications administered to Florida's foster children. Moreover, Florida law does not distinguish between psychotropic medications prescribed for a psychotherapeutic versus a medical purpose.


To make matters worse, case workers and child protective investigators do not even adhere to the department's flawed data entry policy: 5,571 unnamed medications were prescribed to 2,780 foster children for psychotherapeutic purposes, but were not listed as psychotropic in FSFN. In most of these cases, DCF had to obtain parental consent or judicial authorization for the medications, and in many cases there is at least one psychiatric diagnosis listed in FSFN, further confirming that these medications should be counted as psychotropic.


That psychotropic prescriptions are indeed hidden behind the "Other" drug name and medical purpose loopholes is further exemplified by the fact that 4,252 foster children were prescribed 7,327 named psychotropic medications allegedly for medical purposes, even though there was at times a psychiatric diagnosis noted in FSFN. The psychotropic drugs purportedly prescribed for medical purposes include the usual suspects: stimulants, antipsychotics, antidepressants, antianxiety, and mood stabilizers. 


DCF's faulty data entry policies and practices could account for the reported precipitous decline in the percentage of foster children taking psychotropic medications to just 12 percent of the foster care population in Florida. As recently as December 2011, the Government Accountability Office (GAO), based on its review of medicaid claims for foster children in five states including Florida, reported that 20 percent of Florida's foster children were prescribed psychotropic medications.


President Obama has reportedly proposed a $750 Million budget to reduce psychotropic drugging of foster youths that would reward states for lowering their reliance on the drugs. Could DCF be under-reporting the psychotropic medications administered to foster children in order to polish its image in the wake of Gabriel Myers' death, and to better position itself for federal rewards?


Whatever turns out to be the case, it is utterly deplorable that so many prescriptions, whether psychotropic or not, remain labeled as "Other", which ultimately inhibits transparency and the proper discharge of DCF's important responsibilities to our state's foster children.