Foster Youths Meet Psychiatry: A Wickedly Sticky Wicket
July 12, 2016
July 12, 2016
Morning Zen Guest Blog Post ~ Wayne Munchel ~
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. 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 (no planning or reviews for possible discontinuation). Many foster youth don’t even get placed on the category of medications that corresponds to their assigned diagnosis. According to a recent analysis, 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 at risk for 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. An ongoing workgroup 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. Workgroup 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 DSM 5 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 DSM 5, foster youth’s 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-occuring” 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 in disgust.
Developing trauma informed, (First – Do No pHarm?) alternatives will be key to the efforts focused on decreasing 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 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, argues 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 ”dosage”/frequency, and are misdirected at “too high” of a neurodevelopmental stage (focused on cognitive and language processing, rather than more somatic interventions) Clearly much work remains.
Perhaps, one day, after many more billions of dollars in myopic research, a true biomarker or mental illness gene will be identified. (The dispassionate scientist in me, allows that it is possible). In the meantime, can the prominent pachyderm in the room be acknowledged? – that the horrific, toxic stressors that foster youth have endured can lead to many disturbances in their young lives and they will require all the care and support we can muster. It is unacceptable that after suffering so much from the collapse of their family systems, that foster youth and children are further subjected to potential abuses by misguided treatments that carry such high health risks and stigma. Understanding and compassion for “what has happened” to foster youth, rather than “what’s wrong” with them is imperative.
 U.S. Government Accountability Office. (2011). Foster children: HHS guidance could help states improve oversight of psychotropic medication (Publication No. GAO-12-270T). Washington, D.C.: Author. Document Number)
2 PsychDrugs Action Campaign – Youthlaw.org/issues/psyhdrugs-action
3 Crystal, S., Mackie, T., Fenton, M.C., Amin, S., Neese-Todd, S., Olfson, M. and Bilder, S., 2016. Rapid Growth Of Antipsychotic Prescriptions For Children Who Are Publicly Insured Has Ceased, But Concerns Remain.Health Affairs, 35(6), pp.974-982. (Abstract)
4 California Psych Meds Legislation Advances – youthlaw.org/publications
Wayne Munchel, LCSW is a leader in mental health programs designed for transition age youth. He was also a founding staff member of The Village, an innovative recovery program located in Long Beach, CA. Mr. Munchel provides trainings and consultations for services to young people, including trauma informed care and supported employment.