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Why did Florida incarcerate Ashleigh, a mere child?
Ask Jeb Bush, Florida's Republican governor

Published Friday, May 11, 2001

(also see 7 May article below )

Report decried giving drugs to kids
Consultant studied Florida centers for foster care


A consultant hired by the state Department of Children & Families to study residential treatment centers for Florida foster kids reported in February his ``critical'' concern over the ``widespread use'' of psychiatric drugs on children in state care.

The report by child welfare consultant Paul DeMuro was released by the department Thursday only after The Herald had demanded access to the record for two weeks.

Revelations in the report, as well as several others obtained by The Herald on Thursday, shed light on a controversy that has raged for almost a month over allegations by child advocates that children in state care are routinely being given potentially harmful psychiatric drugs in order to control unruly behavior.

The department, which has expressed concern over the allegations, nonetheless insisted Thursday that the use of psychotropic drugs among foster children is neither widespread nor unusual when compared to children who are not in out-of-home care.

A separate internal department investigation into allegations that psychiatric drugs are being used as ``chemical restraints'' on children in state care found that slightly less than 5 percent of the state's foster children are being administered the drug Risperdal, one of several psychotropic medications that have serious side effects.

That investigation reported that 667 children in foster care were taking Risperdal, among 14,649 foster children statewide, said Cecka Green, a spokeswoman for the department in Tallahassee.

About 100 of the children are Miami-Dade foster kids, and another 70 or so live in Broward County, Miami-Dade District Administrator Charles Auslander told The Herald.

Some young children, male and female, have developed enlarged breasts and begun lactating as a result of being administered Risperdal, records and interviews show.

The state has yet to analyze use of several other antipsychotics, which advocates claim also are widely used.

Most of the drugs have been successful in combating fairly common disorders -- such as attention deficit-hyperactivity disorder and at least one form of autism, but advocates assert they are widely used as ``chemical restraints'' for difficult-to-manage children.

DeMuro, whose team studied conditions at seven Florida treatment centers, reported Feb. 10 his concerns about the use of drugs on children in residential treatment centers.

``The widespread use of psychotropic medications is a systemwide issue,'' DeMuro stated in the report made public Thursday. ``DCF needs to seek medical consultation and establish guidelines for the use of psychotropics in residential settings. This is a critical issue, particularly in light of the young ages of many of the children'' in treatment centers.

One teenage boy interviewed by DeMuro's team ``had difficulty staying awake,'' the consultant reported. ``He appeared over-medicated.''

The disclosures have fueled concerns by children's advocates.

``Six-hundred and sixty-seven is an awful lot of kids on powerful medication,'' said Pat Wear, deputy director of the Advocacy Center for Persons with Disabilities.

``Hasn't anybody told DCF to just say no to drugs?,'' said Richard Wexler, a persistent critic of the agency who is director of the Virginia-based National Coalition for Child Protection Reform.

``Here we are trying to send a message to young people about drug abuse, and it is possible that the biggest pusher in the state is the Department of Children & Families,'' Wexler added. ``It is very hard to believe that one out of 20 Florida foster children really needs to be doped up on Risperdal.''

Children & Families officials have insisted that they will not tolerate the use of drugs to restrain difficult children in their care.

``We do not dispense these drugs; we do not prescribe them,'' said Green, an agency spokeswoman in Tallahassee. ``We do put the psychiatric care of children in the hands of professionals. We can only assume that they are using their medical knowledge when prescribing this drug, or any drug, to kids.''

Earlier this week, Gov. Jeb Bush told The Herald his office was ``looking into'' the use of psychotropic drugs among children in state care.

But the governor's office also insisted officials do not believe the drugs are being misused.

Among the documents reviewed by The Herald:

* A February 2000 report by the University of South Florida's Florida Mental Health Institute, a mental health research arm of the school, on 1,200 Broward foster children shows that 56 percent of the kids, or 675 children, had a mental health diagnosis. Among the adolescents, aged 9-15, 45 to 46 percent of the 675 were on some type of psychotropic medication, including such drugs as Risperdal, Ritalin, lithium and Prozac.

The most common diagnosis among the Broward foster kids was adjustment disorder, a diagnosis applied to 38 percent of the 675 children. The second most common diagnoses, at 19 percent, were attention deficit-hyperactivity disorder and/or ``disruptive behavior disorder,'' the report states.

* A consultant who studied a residential treatment program for foster kids at Fort Lauderdale Hospital that was operated until recently by Brown Schools of Florida said that ``all'' the children in the program were being given psychotropic drugs.

``Almost all'' of the children at the Tampa Bay Academy, a Tampa treatment center, were being administered psychotropics, a consultant reported, adding, ``many of [the children are] on multiple psychotropics. The medical director reported that the psychiatrists attempt to use psychotropic medication in as limited fashion as possible.''

At Devereux Florida Treatment Network, another treatment center, the consultant said 80 percent of the residents were being medicated.

And at The Caring Place, a Fort Lauderdale emergency shelter, the consultant said five of 17 teenage boys -- or close to 30 percent -- were on psychotropic medications.

``The use of this medication allows the individual a level of control of their behaviors and assists them in gaining insight to their problems and thus [to] take advantage of the program,'' the consultant quoted a Devereux doctor as saying.

* A review by the Broward Regional Health Planning Council's Behavioral Health Review Team of one residential treatment center, Alternate Family Care, Inc., quoted staff there as saying that a ``barrier'' to the program's success was that ``children [are] being given too many medications.''

Said Howard Talenfeld, a Fort Lauderdale attorney who represents 1,430 Broward County foster children in a pending 1998 federal class-action lawsuit: ``As a means of behavior control, we are institutionalizing kids and putting them
on psychotropic medications.''


Published Monday, May 7, 2001

Advocates alarmed by drugs used for kids
Medicaid children under 6 at issue


Almost 600 Florida Medicaid recipients under age 6 were given powerful psychiatric drugs last year with potentially serious side effects -- drugs marketed to combat an illness that experts say is virtually nonexistent among children their age.

The drugs -- including Clozaril, Zyprexa, and Risperdal -- are marketed for the treatment of schizophrenia and other psychotic disorders in adults, but in recent weeks, children's advocates throughout Florida have expressed concerns the medications are being used to control the behavior of unruly children, especially those in state care.

``I'm starting to get scared here,'' said Jack Levine, president of the Tallahassee-based Center for Florida's Children.

Records from the state Agency for Health Care Administration obtained recently by The Herald show that nearly 400 of the children given antipsychotic drugs last year were under age 5.

All were recipients of Medicaid, the federally funded insurance plan for needy children and adults. Florida's Medicaid office, which is administered by the healthcare agency, keeps detailed records on billing and reimbursement of medications for the needy, but has no direct oversight of doctors who provide care.

The Agency for Health Care Administration, which regulates doctors and other healthcare providers, could take action against a physician found to be negligent.

``We make some basic assumptions about children who need medical care, assumptions about services that are supported by tax dollars, and especially about children who are in the care of state agencies,'' Levine said.

``An assumption I thought we made was that their care would never be appreciably different, in terms of medical carefulness and appropriateness of prescriptions, than everyone else's children. I'm starting to feel there is a remarkable difference in how these children are being looked at, diagnosed and treated.''

The health care administration's records do not specify which of the children are in state care.

The drugs could have been prescribed by family doctors, or doctors under contract with agencies that treat children in state care.

While child psychiatrists say there are legitimate uses for the drugs in treating some more common disorders such as attention deficit-hyperactivity disorder and pervasive developmental disorder, a form of autism, children's advocates were startled that so many children are being administered them.


Last month, The Herald reported claims by children's advocates that hard-to-manage children in Florida's troubled foster care system were being routinely given powerful psychiatric drugs as ``chemical restraints.''

The state Department of Children & Families, which administers the state's children protection and foster care efforts, has insisted that officials do not encourage -- and, indeed, will not tolerate -- the use of drugs as a means to restrain unmanageable children.

Last week, the federally funded Advocacy Center for Persons with Disabilities urged the department to immediately halt all new prescriptions of the drug Risperdal, as well as other anti-psychotic drugs. Risperdal, widely prescribed among children, is the most commonly used among newer antipsychotics.

The group also urged child welfare officials to begin an ``immediate'' and independent investigation into the use of psychiatric drugs among foster children.

Pat Wear, the Advocacy Center's deputy director, said revelations about foster children being chemically restrained have left him ``broken-hearted.''

``Just when you think you've heard all the bad news you can hear, you hear this,'' he said of the large number of very small children being administered psychotropic drugs.


The Department of Children & Families acted quickly. The agency has appointed two high-ranking department doctors to oversee an evaluation of children in state care who are taking the drugs. In Broward, where many of the complaints first arose, a child welfare manager is preparing a spreadsheet listing every child in care, and what drugs they are taking.

Only about 1 in 40,000 people experience childhood onset of schizophrenia, a debilitating disorder often marked by hallucinations, delusions, paranoia and other forms of psychosis, said a spokesman for the National Institute for Mental Health. In contrast, the disorder affects about 1 percent of adults, with onset generally occurring between age 16 and 30.

Judith L. Rapoport, who is the chief of child psychiatry at NIMH, described childhood onset of schizophrenia as very rare.

``No one knows exactly'' how rare, she said, because researchers can't find enough subjects to perform an epidemiology study.

Nonetheless, Rapoport estimates that one child is diagnosed with the disorder for every 300 adults who were diagnosed. As for children below age 7, ``they may exist,'' Rapoport said, ``we just haven't seen any.''

``When you look at very young children, we haven't found a convincing case for schizophrenia where it started before the age of 7,'' she added.


So-called atypical antipsychotic drugs, such as Risperdal, are marketed to combat the psychotic symptoms of schizophrenia, and most have not been specifically approved for use with children -- though it's not unusual for drugs to be administered for an ``off-label'' use.

According to the Agency for Health Care Administration, 389 children under age 5 who receive Medicaid were administered antipsychotics in 2000. Another 200 or so 5-year-olds were given the drugs, as well.

Among the toddlers, 46 2-year-olds were prescribed anti-psychotics, as well as 67 3-year-olds.

Among the 4-year-olds, 177 children were medicated with the drugs in 2000, the agency's records show. Records with the health care agency are unclear for about 59 of the children.

Jerry Wells, pharmacy program manager for the Agency for Health Care Administration, said Children & Families officials also requested detailed data from his agency after an April story in The Herald.

``They were kind of shocked at some of the kids on these drugs,'' Wells said of the DCF officials.


The drugs have been linked to potentially dangerous side effects.

According to records reviewed by The Herald, as well as several interviews, children in foster care administered antipsychotics have experienced lethargy, agitation, tremors and even the development of unusually large breasts. One boy even began to produce breast milk.

``You are talking about some very young children,'' said Mary Giliberti, a senior staff attorney at the Bazelon Center for Mental Health Law in Washington, an advocacy group for people with mental illness, and foster children. ``I'm the mom of a 2-year-old, and I find this very startling and disturbing information.''

``These are very powerful drugs,'' Giliberti said. ``This merits the state taking serious, immediate action.''

Published Wednesday, September 20, 2000, in the Miami Herald

S. Fla. kids 'growing up' in foster care

Average length of stay, as of June 2000, for children in foster care:

Miami-Dade: 56 months
Broward: 39.5 months
State average: 34.3 months
U.S. mandated goal*: 12

*Under Federal Adoption and Safe Families Act of 1997

SOURCE: Department of Children and Families

Despite a federal mandate that kids be moved out of state care within one year, Florida children continue to languish in foster care for nearly three years, a study says.

South Florida's record is particularly striking. Miami-Dade County's foster children spend, on average, 56 months in child-welfare limbo, neither returned to their birth family nor adopted by new families.

Broward County is doing a little better. Broward foster children spend 39.5 months in the system, far less than Dade but longer than those in all other areas of the state.

Federal dollars could be at risk. The federal Adoption and Safe Families Act of 1997, which established the 12-month threshold, authorizes the federal government to reduce or withhold funding for states that fail to comply.

``Certainly, these figures are extremely troubling,'' said Carolyn Salisbury, a law instructor and attorney with the University of Miami's Children and Youth Law Clinic.

``As we all know, children in Florida are growing up in foster care,'' Salisbury said. ``And foster care is no place for a child to spend his or her life. Unfortunately, many children are abused in foster care. Children even die in foster care.''

Charles Auslander, who heads the Department of Children and Families' Miami office, acknowledged, ``we have a very challenging situation that we will have to work very diligently on.''

``We have so many children 13 and older who either grew up in foster care or have grown up in foster care, or grown up in relative care without establishing a permanent'' home, Auslander said.


However, Auslander noted that his office's performance has improved significantly since the 1997 law took effect. In fact, for foster children entering care since 1997, most remain an average of two years, he said.

``The law changed [requirements] so dramatically,'' Auslander said, ``it's almost as if one day we had a new criminal law that said accused people are presumed guilty. It's a watershed change.''

Phyllis Scott, who took over as head of the Department of Children and Families' Broward operations one year ago, said the state's audit portrays a picture that is more bleak than reality. Auditors told Scott they had begun to see significant progress in Broward beginning around May, although the improvements are not reflected in the overall audit.

``There were some areas where we were really way behind,'' said Scott. ``But when we had our exit interview with the auditor, we were told it was very clear they were beginning to see progress -- which was really what we wanted to hear, because we were putting so many new systems in place trying to overcome the decay we found.

``I really think the next audit will show a great deal of progress.''

Throughout the United States, the number of children entering foster care has exploded in the past two decades. Since the mid-1980s, the number of kids entering foster care in America doubled to about 520,000 in 1998.

This year, 18,526 children were in foster care in Florida -- about 14 percent of them in Miami-Dade, and another 11 percent in Broward. Fueling that engine is the enormous number of reports to the Department of Children and Families' abuse hotline, 164,600 in all during the last year.

The Adoptions and Safe Families Act was designed to promote permanence and stability in the lives of such children. It requires states that receive federal foster care money to either return foster children to their parents, or find adoptive parents, within 12 months of their entrance into foster care.

If Florida fails to improve its performance in meeting that goal, the state could lose some of its federal funding, said Linda Radigan, head of Children and Families' Family Safety program in Tallahassee. Federal auditors will gauge the state's performance under the 1997 law for the first time next summer, she said.

``The key for [federal auditors] will be whether or not we are making improvements in areas where they have noted problems,'' said Radigan. ``If not, they could ask for funds back for any service we provided that did not meet their conditions.''

In virtually every area studied, the Children and Families August audit showed the state has a long way to go -- with Miami-Dade and Broward facing the greatest challenges.

Sarasota County fared the best in the audit, achieving 100 percent compliance in nine of 12 key measures. The west coast county's child protection and foster care systems were placed under the private management of a consortium of five community-based groups in 1997, said Chris Card, who oversees the program for the YMCA.


The state auditors studied the foster care records of children in every Children and Families district to measure compliance with federal goals. One measure, for example, was what percentage of children had case plans developed in their files within a reasonable time frame. In Miami-Dade, the number was only 49 percent; in Broward, it was 65 percent.

Another measure was whether the foster child's case plan included ``appropriate tasks for all parties.'' In Dade, that was the case 59 percent of the time, the lowest percentage in the state.

Miami-Dade held last place in several key measures, including whether parents were asked to complete tasks within an ``appropriate'' time frame in order to be reunited with their children. In Dade, that occurred only 35 percent of the time, the study showed.

Dade was in last place when auditors looked at whether foster children's case files documented that ``the child's health needs
are being met through treatment.'' That was true in 66 percent of the files reviewed.

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