Misdiagnosed, Misunderstood, and Overmedicated
How Children in Foster Care Aren't Allowed to Be Children
(For ease of reading, click here to access the website version of this newsletter.)
When I was 11 years old, I had one joy to look forward to each week. Every Wednesday, my foster mother would drive me about thirty minutes away to a Del Taco in San Bernardino, where I’d have one hour to see my mother and brothers. I treasured these visits, but every week, just getting to that fast food joint was like pulling teeth.
My foster mother would start complaining the day before the visit. Sometimes directly to me, other times within earshot. She’d make an off-hand remark to one of her adult biological children about how her whole week would be thrown off because she had to dedicate two hours on a Wednesday to allow the child in her care to participate in court-ordered visits with his family.
On the drive to each visit, she’d let off a long-stream of invective about my family. About my mother, she’d say she cussed too much, or she’d make snide (and increasingly not-so-snide) comments about her past. She saved much of her ire for my brother Douglas, who was briefly placed in her home and was moved for various behavioral issues, such as fighting at school and talking back. She’d talk about the bleak future ahead of him, a future of crime and addiction. He, I should add, was only 14 at the time.
Through gritted teeth, I endured it all, because I was seeing my family. When each visit concluded, she picked up where she left off on the trip home, remarking at what my brothers were wearing or saying, and calling them ‘hoodlums’ and ‘thugs.’ After months of this, I eventually snapped. I spoke up, defending my brothers and my mother. I don’t remember exactly what I said, but this small act of defiance set off a cascading series of events that only made things worse for me.
When my social worker next visited, my foster mother informed her of my attitude. She said that I always misbehaved following these visits, that I had an anger issue. Now, to be clear, there has been evidence suggesting that some children misbehave following a visit with their biological family. And perhaps that was the case with me, but even if that were true, my foster mother was certainly not helping matters by badmouthing my loved ones.
I was signed up for anger management courses. There was talk of putting me on medication. My foster mother pressed to reduce visitations to every other week. I didn’t speak up, primarily out of fear of having my placement disrupted but also because my family wasn’t the type to take insults (especially the ones my foster mother was slinging) lightly.
I was, of course, angry. I believe any child would be, in my situation. But this anger was pathologized. Instead of recognizing that I had a cause to be mad, my anger was wielded as evidence of some deep underlying defect. This was amongst the first lessons I internalized about the foster care system: as a foster child, you are somehow held to a higher standard of behavior, and deviation from this standard is an indication of some deeper issue that must be forcefully addressed.
I can tell dozens and dozens of stories that further illustrate this phenomenon, and I can share the stories of other children who experienced it as well. Put simply, our most vulnerable children aren’t allowed to be children.
To further illustrate this point, reader, ask yourself the following: when you were a teen, did you ever talk back to your parents? Get a bad grade? Slam a door? Stay cooped up in your room? These are universal indications of teenage rebellion and angst, but I know many a former foster kid who were viewed as deviants for engaging in this behavior. I was one of these kids.
Let me be clear, however: there are foster children with extensive needs. Foster youth experience post-traumatic stress disorder at over twice the rate of US combat veterans. Compared to their peers that are not in the foster care system, foster youth are more likely to experience anxiety, depression, and a range of other mental health needs. With what so many foster youth go through, it would be a miracle if they didn’t display at least some anger or act out.
Perhaps it is due to the real and perceived behavioral issues amongst foster youth that they are prescribed psychotropic drugs (designed to treat depression, ADHD, sleep disorders, anxiety, bipolar disorder, schizophrenia, and others) at astonishing rates. According to a 2021 study, one in every three children in foster care are on “psychotropic drugs designed to alter their mental status or mood, a significantly higher percentage than children who are not in foster care within the Medicaid program.”
The independent nonprofit Patient-Centered Outcomes Research Institute found that “tens of thousands of foster youth suffer damage to their health as a result of being unnecessarily prescribed multiple psychotropic medications.” Drugs with sedative qualities have a range of side effects, from diabetes to slow cognition, yet they are being given to thousands of foster children every day, sometimes unnecessarily.
Several states have been investigated for their relatively lax oversight on this issue. For example, over 34% of foster children in Maryland are on some type of psychotropic medication. Last year, a class-action lawsuit was filed against the Maryland Department of Human Services and Social Service Administration alleging that approximately 72.1% of these children lack a psychiatric diagnosis, which might suggest that “psychotropic drugs are not administered in response to a diagnosed mental health condition, but instead are administered as a form of chemical restraint.” Further, the lawsuit states that 53.8% of Maryland foster youth who are taking these drugs are “prescribed multiple drugs at the same time, which is a potentially dangerous practice known as polypharmacy.”
In Texas, a report from court monitors for the Department of Family and Protective Services found a variety of systematic shortcomings (to put it lightly) with the use of psychotropic drugs amongst foster youth in the state, many of which violated the state’s own guidelines on the subject. While the full 119-page report is worth reading in its entirety, here’s a pair of alarming excerpts from it:
“Numerous children at multiple sites were prescribed four or more psychotropics
(excluding medications prescribed for side effects). Of the 161 PMC children whose files were reviewed across 14 sites, 75 (47%) were prescribed four or more
psychotropics.”
“At Camp Worth [Resident Treatment Center], two children were prescribed anxiety medications on an “as needed” basis. Despite this, their medication logs showed that they were administered the medication every morning and evening without any documentation of the reason for administering the medication, in violation of minimum standards.”
The situation was so severe that U.S. District Judge Janis Graham Jack — who ordered the review of psychotropic drug usage in the state’s foster care system — stated the following:
“Does this not set off alarm bells for you that we’re 10 years into this, 12 years into this process, and you all cannot monitor the psychotropic drugs?” Jack asked DFPS Commissioner Stephanie Muth, who took the post in January. “You don’t have the proper people consenting for the use of the drugs. The records are in shambles. The safeguards are not being enforced, your own safeguards.”
In Florida, approximately 1 in 10 children in the state’s foster care system are “given medication typically prescribed for mental health disorders such as schizophrenia, depression, bipolar disorder, and attention-deficit/hyperactivity disorder.” Worse yet, in 66% of the reviewed case files, “logs that record the frequency and dosage of — and any adverse reactions to — were missing.”
I can go on, but the point should be clear by now: children in foster care, who have already experienced untold trauma and have complex emotional needs, are being pumped full of drugs in a dangerous, haphazard, and unaccountable manner. This, seemingly, is true even for children who need this medication, as indicated by the various state reports outlined above.
Here’s another anecdote that might be relevant to this newsletter.
“As a foster child, you are somehow held to a higher standard of behavior, and deviation from this standard is an indication of some deeper issue that must be forcefully addressed.”
At another foster family I was placed with, there were four other teenagers that were placed alongside me. All four of them had special needs, as classified by the state. Or at least that is what I was told at the time.
If I stopped the story there, my foster mother would seem as if she was a model caregiver, someone doing what we all hope is done for children with more complex caregiving needs: give them a home and a family. [Note: I frequently only reference my former foster mothers, but that is only because for the most part, my foster fathers were not heavily involved in caregiving.] I thought so too, originally, given that it is very rare for a foster parent to have foster five teenagers, with or without special needs. But then, my foster mother starting taking me to doctors.
Shortly after arriving at her home, my foster mother took me to get a psychiatric evaluation. I remember a bevy of questions and tests. I did have some behavioral issues at my previous foster home, so perhaps that is what motivated my foster mother to get me tested. Ultimately, I wasn’t diagnosed with anything.
Perhaps, I reasoned, my foster mother was just being altruistic and wanted to ensure any needs I had were being met. But then, she took me to a different facility, to conduct the same tests. She did this a few more times, to different doctors. She even tried to subtly nudge me, to coach me, into saying specific things that might be more likely to lead to a diagnosis, framing it as something that would be beneficial to me. But, alas, no diagnosis was ever made.
This might seem cynical, but I believe my foster mother was trying to eke out some extra money from the state. In California, families who foster children with special needs receive a supplemental payment in addition to the regular payments used to care for that child. In 2008, a family in San Bernardino County caring for a child with a special need could be paid at minimum $79 extra a month. For a child with serious “behavioral disturbances,” families could be paid an additional $184 a month.
Again, I want to be careful: I do not know if this is exactly what was motivating my foster mother, but I have my suspicions. With this said, I can easily see how the practice (if in widespread use) of shopping for a diagnosis could easily lead to an unwarranted prescription of psychotropic drugs.
At any rate, the statistics, reports from the states, and the anecdotes I shared in this newsletter should at least highlight that a new approach to treating foster youth is required.
What can be done, in light of all this? As a disclaimer, I am no doctor (surprise, surprise), but there seems to be a few ways to improve the administration of psychotropic drugs to foster children.
First and foremost, increased accountability doesn’t seem too much to ask for. States should religiously track which medications a child is taking, they should administer drugs in a safe manner that adheres to the state’s own guidelines, and there should be rigorous oversight to ensure no child is taking drugs they are not required to take (or conversely, not taking but should be taking).
Second, state policymakers must make this issue a priority. California, my home state, used to have similar issues with psychotropic drug use on foster children, but between 2010 and 2020, the number of prescriptions for these medications dropped by 58% statewide. Beginning in 2014, multiple laws were passed that sought to rein in the use of these drugs and inject a bit more accountability on how they were being used. One such law was was passed in 2016 that required the sanctioning of doctors who over-prescribed these drugs to foster youth. For those interested, I highly recommend this article, which describes how foster youth felt while on these medications and describes the ways the practice of prescribing them was limited.
Third, other therapeutic services should be made available to foster youth, and importantly, money should be allocated for these services. States should utilize “evidence-based psychosocial interventions” such as Trauma Systems Therapy and Cognitive Behavioral Therapy. Foster parents should be made to receive routine trauma-informed training, as evidence from Sweden suggests that initial trainings tend to diminish over time.
All told, we can do better for foster children by both responding to their needs and letting them be kids.
That’s it for this week!
Current Read(s):
This week, I’m reading The Two-Parent Privilege by Melissa S. Kearney. Just released last year, this book apparently caused quite a stir in some circles. Thus far, I’ve found it quite informative. Kearney, an economist, has a simple thesis, but one with alarming implications: the decline in marriage and the rise of single-parent households have driven inequality higher and reduced social mobility. She marshals a litany of statistics to bolster her case, revealing that across a range of outcomes — such as college completion and lifetime earnings — children from single-parent households are behind, and often way behind, those raised by two parents. This may intuitive to most, and indeed in many ways it is, but the array of facts she brings to the table only hammers the point home. I have yet to reach the “what do we do about it” section of the book, but I will let y’all know what it says when I do.
Last week, I finished Investigating Families by Kelley Fong, and what a moving read it was. I must’ve highlighted half of the book. Fong, an assistant professor in sociology at UC Irvine, conducts in-depth qualitative and ethnographic research, talking with low-income mothers and Child Protection System personnel, all of which combine to paint a devastating portrait to how our country protects children by policing parents, undermining communities, and dismantling families. Here’s a few quotes (of dozens) that I found to be particularly relevant:
“As an idea, a possibility, the [child welfare] system inserts itself into everyday life to undermine familial, social, and institutional relationships. These adaptive responses thwart help-seeking and social solidarity among poor families, including those without prior system contact.”
“Investigators cannot foresee which children will be severely harmed (or even die) after investigations close—none of us could. But they are on the hook if they miss something that turns out to be pivotal. So covering themselves means looking into everything they might be held accountable for, in all cases, and documenting their efforts.”
“When our tool is the CPS hammer, everything becomes a child maltreatment nail. CPS collects poverty problems but can really only deal with parenting problems . Its response initiates extensive surveillance of family life. It assesses families through the lens of future risk, subjecting the most marginalized families to ongoing state oversight.”
If you want to know how the child welfare system functions on-the-ground and in communities, this is one of the best books on the subject.
What’s going on in the world of child welfare?:
Christian Bale Breaks Ground on Palmdale Center that Will Keep Foster Siblings Together (ABC7) — Batman delivers! The Australian actor has decided to build a 7000-square-foot community center in Palmdale, California, designed to keep siblings together. The center is scheduled to be finished in April 2025.
Senate Bill Could Spare Kinship Care Families In Kentucky From Making A Costly Decision (Kentucky Lantern) — A bill proposed in the Kentucky State Senate would allow children who are removed from their parents the option to list potential caregivers, while also helping kinship caregivers have access to financial assistance.
Why Mandatory Reporting Doesn’t Keep Children Safe (Time Magazine) —This article gives a brief history of one of the most consequential pieces of child welfare legislation in the country: the Child Abuse Prevention and Treatment Act (CAPTA). This bill is what gave rise to mandatory reporting, which the author argues has led to states surveilling families more than supporting them.
Taxpayer Spending on Court-Appointed Special Advocates for Foster Kids Surges, but Evaluation Lags (The Imprint) — CASA, an organization very near and dear to my heart, pairs a volunteer with a child involved in the child welfare system. This article argues how there hasn’t been a robust evaluations of whether this approach leads to positive children, despite it receiving taxpayer dollars.
Measuring the Impact of CASA/GAL Model (The Imprint) — Tara Perry, the CEO of the National CASA/GAL Association for Children, pushes back on the argument presented in the article listed above.
New Bill Would Allow Foster Children to Choose Their Families (KWCH) — A bill in Kansas, called SOUL Family Legal Permanency, would allow foster youth ages 16 and above the opportunity to chose their legal families. This bill was motivated by the fact that many children age out of the system without “establishing lasting family connections.”
Native American Child Welfare Bills Return After Federal Law Upheld (South Dakota Searchlight) — Child welfare advocates (especially Indigenous advocates) waited in bated breath last year as the Supreme Court considered the fate of the Indian Child Welfare Act (ICWA). Fortunately, the law was upheld, and now legislators in South Dakota have advanced legislation that will further protect Indigenous children within the state.
California Foster Youth and COVID Orphans Gaining a Sense of Hope from Trust Fund Program (CalMatters) — This article, written by a senior in high school and a current foster child, highlights the transformative impact of the new Hope Program, which will give $4,500 to approximately 58,500 children on their 18th birthday. As the title of the article suggests, this program is designed for foster youth and those who have lost parents to COVID.
In 2024, Will Virginia Finally Address its Poor Outcomes for Children in Foster Care? (Virginia Mercury) — This article discusses a variety of shortcomings in the child welfare system in Virginia, such as the lack of adequate legal representation for families involved in the system and its poor rate of family reunification.
Bipartisan Bill Would Expand Federal Extended Foster Care Program (The Imprint) — 28 states, nine tribes, and DC have extended foster care in place, which allows foster youth to remain in the system until they turn 21. Among other things, this proposed legislation would clear barriers for the rest of the states to enact extended foster care.
Housing Vouchers Keep MS Families Together, Reduce Number of Children Entering Foster Care (Clarion Ledger) — Yet another article that demonstrates what should be obvious: if you address a family’s material hardships (such as a lack of housing), you can reduce the need for the foster care system.
California Governor’s Budget Breaks His Promise to Older Foster Youth (The Imprint) — Written by a former foster child, this article discusses how Governor Newsom (citing budget concerns) has rescinded a proposal to boost funding to a cash assistance program designed to help emancipated foster youth.