How to keep foster children off psychotropic meds in one easy lesson

            The issues in politics are not complex, even though the politicians tell us so to convince us of their importance – and to keep us from criticizing them.

--Costa Gavras

The issue of the misuse and overuse of powerful, dangerous psychiatric medications on foster children finally is getting some of the attention it deserves at the national level.

It was the subject of a GAO report and a comprehensive study from PolicyLab at the Children’s Hospital of Philadelphia.

Most important, it’s a top priority of the nation’s highest-ranking child welfare official, George Sheldon, who runs the Administration for Children and Families.  He led efforts to curb the use of these medications when he ran the Florida Department of Children and Families.  He’s convened a summit on the issue, bringing together officials from all 50 states, at the end of August.

But in child welfare there always is the danger that latter-day “child savers” will try to make complicated what really is not – in order to convince us of their importance, keep us from criticizing them, and avoid actually doing anything about the problem. 

A reminder of why this issue really is not complex comes this week in a superb dissection of child welfare in New York City, published in the New York Review of Books.   (Most of it is behind a paywall, but it’s well worth the $4.99.  

This article, when read along with the stories in the current issue of City Limits, like this one, and last year’s New York Magazine story on the real world of caseworkers, offer a definitive portrait of the real state of child welfare in New York today – and how it got that way.

There is much that is outstanding about this most recent article, including its keen understanding of the history and current reality of child welfare in New York, and the vital role of groups like the Child Welfare Organizing Project in improving that reality for thousands of families.  (Over the years, NCCPR has received grants to help CWOP with media work.)

The story also includes this case example, which will be followed by a pop quiz:

[A] mother who was in a drug treatment program lost her child after a single relapse.  For a while, mother and daughter were allowed to meet regularly at a desolate Bronx foster care agency beside a gravel yard where garbage blew around like tumbleweeds.

One day, when the child appeared with a black eye somehow acquired in her foster home, the mother became hysterical, and the police were called. The child was placed in a new foster home, but after that, mother and daughter spiraled into madness.

While scrambling to assemble court documents, the mother managed to obtain the original report filed when her daughter was first taken away. This document, signed by the New York State commissioner for children and family services, states that the original allegation of neglect was “unfounded”—aside from the single drug relapse, the report said the child was well taken care of.

Nevertheless, because of the mother’s angry outbursts, she lost her parental rights last February. Her daughter, now eight and taking four psychotropic medications to control her behavior—including one that can cause irreversible catatonia and drooling—is, the mother told me, up for adoption.

So, here’s your pop quiz: What would have been the best way to prevent this girl from winding up “taking four psychotropic medications to control her behavior—including one that can cause irreversible catatonia and drooling.”

Any questions?

Foster care in Nebraska: Signs of real progress – but the rate of removal in North Platte is insane

For years, NCCPR, along with outstanding state advocates like the Family Advocacy Movement in Omaha, have been sending one message to the child welfare establishment in Nebraska: The state must get its obscene rate of tearing apart families under control.

Now it looks like the message is getting through.


UPDATE, SEPTEMBER 12:  Thomas Pristow, Director of the Division of Children and Family Services in the Nebraska Department of Health and Human Services, has written to NCCPR to explain the discrepancy discussed in the August 24 update below.  He says Nebraska gave the same figures to the federal government and to the voluntary database.  But, he says the Nebraska "Court Improvement Project" asked   the organization maintaining the voluntary database to adjust the figures to remove children placed in foster care through the state agency dealing with juvenile delinquency.  Pristow does not explain why the Court Improvement Project made this request.  The Supreme Court Commission on Children in the Court, a key part of the Court Improvement Project, includes three places for top officials of DHHS.  

Unfortunately, Pristow did not mention any of this when he first wrote to NCCPR on July 6 to take umbrage at even the slightest suggestion that his agency might have fudged the figures.  Indeed, Pristow did not investigate the discrepancy until after we pointed it out in the update below.

UPDATE, AUGUST 24, 2012: It now appears that the message has not been getting through to the extent that I'd hoped.  In the post below, I warned that the state might be fudging the figures.  That appears to be what happened.


The source for the data on which this post is based is a set of figures Nebraska reported to a voluntary database.  The federal government has a separate database.  States are required to report entries into care to this database, and there are specific rules for what constitutes an entry into care.  

The federal Department of Health and Human Services has just released figures from that database for the year ending September 30, 2011 – the same time period discussed in this index.  The figures are available here. 

Nebraska reported a much higher figure for the total number of children removed from their homes to this database: 3,151.  In contrast, Nebraska reported only 2,540 entries to the voluntary database.  

So the statewide figure in the NCCPR Nebraska Rate of Removal Index should be considered invalid.  However, the index still probably gives an accurate indication of how counties in Nebraska compare to each other.  In other words, if the state fudged the figures, the state probably fudged those figures the same way in every county.

Today NCCPR releases its Nebraska Rate of Removal Index, which compares rates of child removal for the Nebraska counties that include more than three-quarters of the children removed from their homes.

These are new data, not yet released by the federal government, for the year ending Sept. 30, 2011.  The key findings:

● If the data are accurate (that is, if the state Department of Health and Human Services did not fudge the figures) Nebraska reduced the number of children torn from their parents by 25 percent over the previous year, an important and impressive change in direction.

● However, even with this decline, Nebraska still is taking away children at a rate that is among the highest in America.

● There are significant variations within the state.  The rate of removal in Lincoln County (North Platte) is insane – nearly double the state average.  In fact, the rate of removal in Lincoln County is so high that, were this county its own state, it would have, by far, the highest rate of removal of any state in America.

● Scotts Bluff County, Madison County, and Lancaster County (City of Lincoln) also are alarmingly high, even by Nebraska standards.

● This jibes with what the Family Advocacy Movement has been hearing anecdotally about the behavior of DHHS, the courts, and law enforcement in these counties. 

● None of the measured counties in Nebraska is as low or lower than the national average.

● The data show no correlation between high rates of removal and improved child safety – as measured by the key outcomes used by the federal government.  These data also are available in the NCCPR Nebraska Rate-of-Removal Index.

The full press release, and the full Rate-of-Removal Index, which includes links to the raw data from which it is compiled, are available at the Nebraska Resources Page at www.nccpr.org 

Foster care in America: Rutledge Q. Hutson is gloating - and that’s never good news for children

Regular readers of this blog might remember Rutledge Q. Hutson.  Her formal title is Director of Child Welfare Policy at the Center for Law and Social Policy.  A better title would be Leader of the “Yes, but…” Brigade that tried to stop Congress from enacting waivers from federal child welfare financing restrictions.  Those restrictions limit a huge pot of federal child welfare aid to funding foster care and nothing else.

Hutson is an expert practitioner of a standard tactic of America’s latter-day “child savers:” never say no to a good idea, just “yes, but…” it to death.

Despite her best efforts, Congress passed a law restoring the authority of the Department of Health and Human Services to issue up to ten child welfare waivers per year for the next three years.  But what Rutledge Q. Hutson and her allies couldn’t do in Congress, they managed to do through their man on the inside, Bryan Samuels, who runs the Administration on Children Youth and Families within HHS.  As is discussed in previous posts to this blog, Samuels has issued guidelines that effectively undercut the intent of waivers – to reduce needless foster care.  Instead, the guidelines seek to turn waivers into a program to make foster care “better” by providing more “services” to improve children’s “well-being.”

So it’s no wonder that last week, Rutledge Q. Hutson couldn’t resist gloating.  She took her victory lap during a meeting of representatives of various child welfare organizations.  For starters, she admitted the obvious: That she had, in fact, been against the waivers all along.  But not anymore.  Bryan Samuels had so radically altered their true purpose that Hutson was thrilled.  In particular, she’s ecstatic over the fact that waivers won’t be evaluated based on whether they keep children safely out of foster care and prevent reabuse. Instead, for a waiver to be successful it will have to show it also improved these children’s “well-being.”

This ignores two salient facts:

● The purpose of child protective services, the agency that can come into your home and take away your child, is not, in fact, to apply subjective judgments about that child’s “well-being.” Rather, its purpose is to prevent children from being abused.

● One of the best ways to improve any child’s “well-being” is to get him out of foster care if he’s already there and keep him out if he’s never been taken away.

Like almost all child savers, Hutson means well.  After all, the very first child saver, Charles Loring Brace, who, in the 19^th Century, engineered the confiscation of thousands of poor Catholic immigrant children and shipped them off to the south and Midwest to be raised by Protestant families, also meant well.  He sincerely believed Catholic immigrant parents were genetically inferior, and his scheme was essential for their children’s “well-being.”  Both Charles Loring Brace and Rutledge Q. Hutson have devoted much of their professional lives to a vision for helping vulnerable children.  The problem isn’t the good intentions, the problem is the lousy vision.

INVASION OF THE “WELL-BEING POLICE”

Turning child welfare agencies into Well-Being Police sets up both waivers, and parents, to fail.  It actually risks increasing entries into care in states with waivers.

That’s because it compounds one of the biggest problems in the system right now: the fact that once a parent loses a child to foster care that parent actually is held to a higher standard than a parent who never had child protective services in her life in the first place.

For example, no law says that a person who is unemployed can’t have a child.  But once a child is in foster care, getting a job – not just any job, but a job that satisfies the whims of a caseworker - often is a condition for getting the child back. Similarly, no law says that parent who lacks housing deemed suitable by a caseworker can’t have a child.  But once the child has been taken away, regardless of the reason, “suitable housing” often is a condition for getting a child back.  Witness these cases from Texas and South Carolina.

Now, under the Samuels waiver guidelines, the bar for getting a child back and being allowed to keep that child is raised still higher.  Waiver success, and therefore, parental success, is to be judged not only based on whether the parent does not abuse the child, but also on the basis of whether all sorts of “well-being” indicators improve.  So if a waiver keeps children safely at home but they still do poorly at school, that’s a failure.  If a waiver keeps children safely at home but they still have the same emotional problems (plus those that may have been caused by foster care) that, too, is considered a failure of the waiver and the parent.

Obviously, that ratchets up the pressure on parents.  And it creates a back door to bring the coercive power of child protective services far deeper into a family’s life.  In short, it gives child protective services even more grounds to tear apart families and hold children in foster care.

Gwendolyn Clegg, a parental defense attorney in Oklahoma, aptly summed up the problem with this approach in a recent article in the Tulsa World:

"Social workers want to fix all the issues in the whole family. I'm not saying that's a bad thing. …[but] The law only requires you be a D-plus parent, meaning it only requires them to correct the reasons their kids came to us.”

Of course that kind of statement gives a lot of my fellow liberals (especially Rutledge Q. Hutson-type liberals) apoplexy.  After all, shouldn’t every child have A-plus parents?

Well yes.  But not by government force or fiat.

There are all sorts of ways government can and should improve children’s well-being.  Government could ensure that every American has decent health care.  Government could pour funds into low-performing inner city schools (and, by the way, stop scapegoating the people who teach there.)  Government could guarantee access to high quality day care and preschool.  Government could ensure that no American is homeless or lacks decent housing.

Every step the government takes to reduce the scourge of poverty will improve all children’s well-being and help parents do an A-plus job.  And not one of those steps involves imposing on families the extremely dangerous, coercive power of the state.

When it comes to what government should be able to do by force of law to a family, it should indeed require no more than D-plus parenting.  There are a lot of good reasons for that, not least the fact that, foster care so often produces D-minus outcomes for children.

The idea of government as Well-Being Police also plays right into the hands of those on the far right who love to stereotype all liberal ideas, and undercut all efforts of government to offer a true helping hand, by exploiting the extremism reflected in the Hutson-Samuels approach.

WATCHING THE WAIVERS

Does this mean waivers are doomed to do more harm than good?  Not necessarily.  The actual federal law creating the waivers includes none of this nonsense perverting their intent.  What Samuels has issued are guidelines.  Waiver proposals that focus on their rightful purpose, safely reducing foster care, and on measuring success by seeing if foster care is, in fact, safely reduced (as determined by things like reabuse rates and rates at which children are returned to foster care) still can be approved, particularly if there turns out not to be a lot of competition for the ten available each year.

And the public will have some voice, at least in theory.

The first round of waiver proposals are due on July 9.  At some point thereafter, ACYF will post the proposals on its website and solicit public comment.  So check back then and see if your state has submitted a waiver proposal.  Then speak out – for it if it meets the true purpose of waivers, and against it if it’s the kind of waiver that would make Rutledge Q. Hutson and her latter-day child saver allies jump for joy.

Because the final decision rests with someone who understands what a waiver is supposed to do.

ACYF is part of the Administration for Children and Families, which is run by George Sheldon.  Back when he was running the child welfare system in Florida, which implemented a classic waiver with great success, he testified at that same hearing as Rutledge Q. Hutson.  During that hearing Sheldon talked about meeting with former foster children:

Child after child after child told me I would have rather stayed at home and dealt with the issues in that home than gone into a foster care system where I was moved from home to home and school to school.

So the best hope, maybe the only hope, for what should have been the biggest change for the better in American child welfare in decades is that George Sheldon will show Bryan Samuels who’s boss.

Foster care in South Dakota: The state goes after another child welfare whistleblower

            It’s hard to say in which state it is most dangerous to take on child protective services – but a good case can be made for South Dakota.

            For the second time in less than a year, South Dakota authorities allegedly retaliated against a whistleblower who sought to change the state’s horrific child welfare system, a system whose failings were exposed in a Peabody award-winning series by NPR last fall.

            The first instance concerns Robert Doody, executive director of the South Dakota branch of the American Civil Liberties Union.  Shortly after he announced that the South Dakota ACLU was looking into the NPR stories and gathering cases for a possible class-action lawsuit, his own child was taken from him.  As of May 1, that child still was in foster care.

            But now, it turns out, even a prosecutor may not be immune from the long, vengeful arm of South Dakota authorities.

            Brandon Taliaferro used to be in charge of prosecuting real child abuse in Brown County, which includes the City of Aberdeen.  But according to a report from the Lakota People’s Law Project (LPLP), that didn’t blind Taliaferro to the abuses of the South Dakota Department of Social Services.

           On his own, Taliaferro had drawn the same conclusions as NPR: South Dakota DSS repeatedly tore apart Native American families needlessly, and South Dakota repeatedly violated a federal law, the Indian Child Welfare Act (ICWA). For that he lost his job.  According to the LPLP report: 

Mr. Taliaferro was fired after a face-to-face meeting with D.S.S. official Virginia Weisler and D.S.S. Chief Counsel Daniel Todd. In that meeting D.S.S. Officer Weisler and D.S.S. Chief Counsel Todd accused Mr. Taliaferro of “not being a team player” and of “being disloyal to the D.S.S.”

            Taliaferro was fired by Brown County state attorney Kim Dorsett.  No one would accuse her of being disloyal to DSS – particularly since Dorsett had a $75,000 contract to represent DSS – a lot more than she was being paid to be Brown County state attorney at the same time.

            According to the LPLP report:

On December 19, 2011, The Aberdeen News reported that Mr. Taliaferro “said that it is financially beneficial for the department to remove American Indian children from their homes and place them in [white] foster homes.” Mr. Taliaferro said that, over the years in which he served as the Assistant State Attorney in Brown County in charge of prosecuting abuse & neglect cases, he and the D.S.S. were “often at odds.”

In official papers filed with the State Department of Labor in his appeal of his firing, Mr. Taliaferro charged that “following the orders of State Attorney Dorsett would have required [me] to violate the law, and ethical rules that govern attorney conduct.” Referring to the unlawful South Dakota state policy of systematically violating the Indian Child Welfare Act, Mr. Taliaferro asserted that he refused to participate in “a cover-up of misconduct” by the D.S.S.

COVERING UP ABUSE IN FOSTER CARE?

            But state officials weren’t through with Taliaferro. 

This part of the story begins with the placement of four Native American girls, ages 7,9,14 and 16, in a white foster home in Brown County.  They were placed over the objections of the children’s adult sister, who offered to take the girls in.  Federal law encourages states to give preference to relatives whenever a child must be placed in foster care, and the Indian Child Welfare Act requires it when the children are Native American.  The whole thrust of the NPR stories, of course, was South Dakota’s contempt for ICWA and its horrendous treatment of Native American children.

            The older girls complained that they were being sexually abused by the foster father, and the foster mother threatened to punish them if they told authorities.  Taliaferro investigated and concluded that the allegations were true.  He charged the foster father with 23 felony counts of aggravated rape of a child and aggravated incest.  The foster mother was charged with 11 felony counts of aiding and abetting the foster father’s crimes.

            Taliaferro was supported by Shirley Schwab, the director of the Court-Appointed Special Advocate (CASA) program in the county.  That, in itself, is extraordinary, given that CASA usually shows a profound bias in favor of foster parents and against birth parents.

            According to LPLP, these charges came after repeated reports were made to the South Dakota Department of Social Services alleging abuse by the foster parents.  DSS refused to investigate.

            But DSS and the state attorney general were a lot more aggressive about going after Taliaferro and Schwab. 

            The attorney general and the state Department of Criminal Investigation have charged Taliaferro and Schwab with “unauthorized disclosure of child abuse information” and “witness tampering” According to the LPLP report, Taliaferro and Schwab say these agencies are “actively coordinating with DSS officials” to use these “fabricated allegations” to discredit the evidence against the foster parents.  LPLP notes that the charges were brought  “immediately after the embarrassing [NPR] expose” of South Dakota DSS.

           The foster father ultimately pled guilty to one count of rape of a child under ten years old.  He will be sentenced to 15 years in prison, with parole possible after five.  According to LPLP, prosecutors originally planned to dismiss all of the charges against the foster father, except for one misdemeanor charge of spanking one child.  Only after the birth family expressed its outrage at the secret deal were the charges upgraded.

            LPLP reports that its investigation

revealed a common pattern: South Dakota state prosecutions tend to dramatically downplay criminal abuse cases brought against white foster care parents when Lakota Indian children are the victims. On the other hand, our investigation shows that Lakota parents are systematically treated more severely by D.S.S. than are white parents for virtually identical conduct. Indeed, over the last ten years, Lakota children in South Dakota have been systematically removed from their Lakota parents under factual circumstances under which white children would never have been taken away from their white parents. This is exactly the conduct of which former Assistant State Attorney Taliaferro accused D.S.S. officials,

           

            A hearing on the charges against Taliaferro and Schwab is scheduled for Wednesday.

Medicating kids in foster care: Turns out that’s arbitrary, capricious and cruel, too

            What are the odds that a foster child in Kentucky is two-and-a-half times more likely to need to be doped up on potent, sometimes dangerous psychiatric medications, than a foster child in Washington State?

            What are the odds that Kansas foster children really need those drugs nearly three times as often as Pennsylvania foster children?

            How likely is it, really, that a foster child in Texas is more than seven times more likely to need these risky drugs than a foster child in Hawaii?

            Common sense suggests the answer.  Yet these are some of the actual differences in rates at which these drugs are used, according to a recently-released study.

            The study, from PolicyLab at the Children’s Hospital of Philadelphia, compared data on the use of “second generation antipsychotics” on foster children in 47 states and the District of Columbia between 2002 and 2007.  These drugs have become notorious in child welfare circles because, to use the genteel words of the study

these drugs are prescribed to address disruptive behaviors in children despite limited efficacy data and emerging evidence of metabolic side effects that have questioned their use in pediatric populations.

            In other words, their primary purpose often is to keep foster children doped up and docile for overloaded caretakers – notwithstanding the grave risks the drugs may pose to the children.

            The study also looked at the percentage of foster children taking multiple psychotropic medications at the same time.  Here, too, the study found wide variation among the states.

            Both the study and an accompanying press release focus largely on the trends – the extent to which the use of these medications has been increasing or decreasing.

            But at least as significant is the enormous variation among the states. 

We already know that the rate at which children are taken from their parents varies enormously by state.  For example, a child in Iowa is four times more likely to be taken away than a child in Illinois, even when rates of child poverty are factored in.  Yet independent monitors have found that Illinois’ efforts to curb needless foster care have improved child safety.  So either Iowa is a cesspool of depravity with four times the child abuse of its neighbor to the east, or Iowa tears apart far too many children.

The new study suggests that decisions on whether a foster child will be doped up with potentially dangerous psychiatric medication are just as arbitrary, capricious and cruel as decisions about whether to take a child in the first place.  Or as a summary of the study puts it: “…where a child lives seems to influence their chance of being prescribed a psychotropic drug at least as much as the child’s medical needs.”

Texas long as been notorious for the misuse of meds.  Take a look at the “before” and “after” pictures from this story by a Texas television station.  That was just one case.  A segment of the PBS series Need to Know gave an excellent overview of the problem in that state. 

Now, it turns out that the Texas is the doped up foster child capital of America.  More than one in five foster children was on just this one class of medication, second generation antipsychotics, in 2007.  In Hawaii, which uses these medications the least, the figure was 2.8 percent.

GRANDMA VS. THE RX PAD

Unfortunately, the researchers failed to draw one distinction which might explain part of the discrepancy.  The study does not compare the use of meds based on where a child is placed. 

It turns out that once a child is in foster care, the best protection against needless medication is – grandma.

As has been noted previously on this blog, when Florida started looking closely at the problem, the state found that, when foster children are institutionalized, 26 percent of them are medicated. When they're placed with strangers, it's 21 percent. But when foster children are placed in kinship care with extended family, usually a grandparent, only four percent are prescribed psychiatric meds.

It's not hard to figure out why: Grandparents and other relatives are more likely to love these children, and so will tolerate more difficult behavior before demanding a prescription. That's just one indication that the best solution to the misuse and overuse of meds on foster children is not a new law – it's grandma; or, better yet, keeping more children out of the system in the first place.
 

            According to this latest study, Hawaii does best at avoiding doping up foster kids.  Hawaii also is the national leader when it comes to placing those children with relatives.  Florida, which is second best in the nation on kinship care, also did better than all but five other states (of the 47-plus-DC measured) in avoiding using psychiatric meds on foster children – and that was in 2007, before the state began a concerted effort to curb overuse of these medications.  Illinois has the fifth best record on kinship care, and does better than all but nine of the measured jurisdictions when it comes to medication.

            Conversely, Arkansas, Delaware, Virginia and Kentucky all are among the worst both for medicating foster children and for using kinship care. 

            Of course the pattern doesn’t always hold.  Texas actually uses kinship care at a rate above the national average, even as it is worst-in-the-nation for medicating foster children.  But odds are that simply means the proportion of children placed with strangers and institutionalized is so obscenely high in Texas that the use of kinship care doesn’t make up for it.   

            It would have been helpful had the researchers broken down the medication rates  for each state by placement type, if such data were available.

            It also would have been helpful had the researchers thought more about the implications of their own findings.  The only solution they can think of is throwing more therapy and counseling at foster children as an alternative to medicating them.  But the fact that kinship caregivers, who typically get less help than what should properly be called “stranger-care parents,” still resort to drugs so much less often suggests another possibility.  The researchers need to consider whether, for many of these children, it’s foster care itself that’s causing their problems, and return to their own homes or, at least, placement with a relative, might be the best therapy of all.