Child's suicide raises medication questions

January 10, 2010

Child's suicide raises medication questions

By DEBORAH CIRCELLI
Staff writer

DAYTONA BEACH -- Little bodies sink into adult-sized conference chairs.

With crayons between their fingers, they color on a sheet of paper after writing promises to their parents -- "to control my anger," "to make good grades" and "to go to the good side" when deciding what path to take in life.

In a room at Halifax Health Behavioral Services on Jimmy Ann Drive, 10- and 11-year-olds are dealing with adult issues -- depression and mood swings.

For Walter Grimes, 11, his quiet demeanor is a sharp contrast from court documents describing a child in a school summer program who bit a teacher on both of her arms and punched and kicked her in the face. Walter, who was 10 at the time, was taken to Halifax Health Behavioral Services under the state's Baker Act as a threat to himself and others and charged with battery on a school official, records show.

Therapy and psychotropic medication -- medicine used for psychiatric reasons such as mood stabilizers, stimulants and drugs for attention deficit hyperactivity disorder -- are helping him stay calm and concentrate, his therapist and great aunt said.

The question of how much is too much and how young is too young when it comes to prescribing psychotropic medications -- some that are not approved for children by the Food and Drug Administration -- is a statewide and national debate.

In Florida, 81,961 children covered by Medicaid were on psychotropic medications from January to June 2009, compared to 76,358 from January to June 2008, according to the state Agency for Healthcare Administration. Numbers for private health insurance companies are not public.

Local agencies are seeing a rise in the number of children with psychiatric problems, from severe anxiety to depression. They're also seeing more young children who are 5 or 6 years old. The concern is especially high in foster care, where a higher percentage of children are given psychotropic drugs than in the general population.

The April 2009 death of a South Florida 7-year-old foster child, Gabriel Myers -- who was prescribed several mind-altering drugs and hanged himself in his foster home -- sparked a statewide review and recommendations in November that will result in new rules and legislation in the coming months for children under foster care.

"We must do better for our children," said Alan Abramowitz, former local DCF administrator and state director of the DCF Family Safety Program Office. "Medication is not the cure-all."

Adderall is the psychotropic medication prescribed statewide in foster care to the largest number of children for attention deficit hyperactivity disorder, DCF records show. Locally in foster care, the main psychotropic drug being prescribed is Seroquel for mental/mood conditions.

Some child advocates question whether medications -- some of which have serious side effects such as suicidal thoughts -- are being used as a quick fix to behavioral problems that children will grow out of because their brains are still growing.

"It shouldn't take mind-altering medications to help children grow up," said Karen A. Gievers, a child advocate and an attorney in Tallahassee. "It takes good parents to help children grow up."

Others say some children need medications to help them concentrate and succeed in life. Some are being exposed to more violence at home and dealing with issues not seen a decade ago.

"We get children who haven't giggled or laughed or smiled in years," said Shirley Holland, department manager at Halifax Health Behavioral Services, the local community mental health provider for children. "Once we add medication, it's like the light goes on. They experience life in a completely different way. It doesn't mean the burdens go away, but life is not so heavy."

MORE CHILDREN BAKER-ACTED

Halifax Health Behavioral Services has seen the number of children admitted under the Baker Act as a danger to themselves or others almost triple in Volusia and Flagler in a three-year period. The agency treats about 3,000 children in all its programs -- more than half are on psychotropic medications.

The reasons behind the rise are unclear, but some point to children being subjected to more stress at home.

Holland said it would be unusual about 20 years ago to see a 12-year-old who was psychotic, hearing voices and hallucinating, but "they are younger than that now."

She recalled a 5-year-old in 2009 who broke glass and swallowed it after stating he wanted to kill himself.

With a child or adolescent attempting suicide every 90 seconds in this country, Holland asked how can her staff not treat and help children have a better quality of life.

For Walter Grimes, he and his four siblings were adopted by their great aunt in 2008 after being removed from their parents by DCF. Carrie Hill, his great aunt, said the children dealt with issues of abuse and neglect, including sometimes sleeping on the floor when their cots broke. When he first came to live with her three years ago before he was adopted, Hill was often called to the school by police and administrators.

There were times he would "curse at me, hit me and spit on me," she said.

Now, after being on medication for mood swings, Walter is making good grades and has certificates for scoring high on the FCAT in reading, but Hill said he still has more work to do.

"I was worried to put him on medicine, but I asked a lot of questions and talked to doctors and they helped me," Hill said. "He has come a long way. He's a sweet child and he's very lovable and he has a beautiful smile. It's just these issues he's dealing with."

At his Daytona Beach house recently, Walter was quiet and shy as he read his favorite book, "The Lion King," to Hill, whom he calls "Auntie." He said he loves to read because "it's fun."

The fourth-grader said he's learned in therapy how to control his behavior by taking time to think about the situation, breathe or walk away if he is angry. He said the medicine "helps me stay calm. I don't mind (taking it)."

Vanessa Harvey-Lents, program therapist at Halifax Health Behavioral Services, told children in the group recently they always have a choice to do the right thing. She told them that while the medicine they take calms them to think and make the right decision, they have to control their behavior.

"There is no cure to bad behavior," she said.

UNKNOWN DRUG SIDE EFFECTS

Others worry children are being overmedicated and, in some cases, put on medications not approved for children, with unknown long-term side effects.

Dr. Christopher Bellonci, , a psychiatrist in Massachusetts and national expert who has testified before Congress and Florida child-welfare officials, said some psychotropic medications used for aggression in children can have serious side effects, from weight gain to diabetes and heart disease. He thinks there is "over-prescribing."

He points to the diagnosis of bipolar disorder increasing 40-fold in the last decade. Part of the problem, he said, is the "societal viewpoint" that medications are the answer and will be easier than doing therapy and behavioral work.

"I don't know that kids are any more ill than they were a decade ago," Bellonci said. "But if you look at the diagnostic percentages, you are seeing huge increases in the way people are diagnosing these kids."

Maryann Barry, CEO of the Children's Advocacy Center in Daytona Beach, which provides therapy services to abused children, is concerned some children are being treated for mental illness when in truth "the problems are environmental or behavioral." If there is a child in a violent, disruptive home, she said, the child will have violent or withdrawn behavior.

"Their body and mind is responding to that environment," Barry said.

But Dr. Hilda Vega, a child and adolescent psychiatrist at Halifax Health Behavioral Services, said she looks at a variety of factors before deciding whether to place a child on medication, including the child's pathology and his environment at home and school.

The youngest child she put on medication was 3 1/2 and was aggressive at home and in day care. But the family also saw a behavioral analyst.

In "an ideal world," where there are no problems or illnesses, she said, she would not put any child on medicine. But she said, "we do not live in an ideal world."

The brain is an organ, Vega said, and it also gets sick, which affects behavior and mood. Medicine, Vega said, helps regulate and stabilize. Many times children don't have to stay on the medication into adulthood because, she said, they learn coping and organizational skills.

VIOLENCE AT HOME

"Our" Children First in Daytona Beach, which provides counseling and services to children and families, is seeing an increase in children who are depressed and making suicidal statements or threatening violent acts. In some cases, agency officials said, those children also have ADHD and their academics are impeded. Young children are being put on sleeping medication because of severe anxiety and post-traumatic stress, said Fran Moccia, the agency's CEO.

"Children are seeing their mother shot and killed on the front lawn," Moccia said, referring to a local Daytona Beach case and similar cases in West Volusia and Palm Coast where children were present when their mothers were shot. "There is so much violence every time you turn around.."

Crystal Knight, the agency's clinical director, said while coping skills are taught in therapy, some children are not developmentally able to learn those skills and need medicine in conjunction with therapy.

"Sometimes counseling is just not enough," Knight said.

Dr. Michael Bell, a DeLand pediatrician, said he's shied away from prescribing psychotropic medication since the federal government issued warnings that some medications could cause suicidal thoughts in children. Instead, he refers children to a psychiatrist.

But Bell, who is also medical director of the child protection team at the Children's Advocacy Center, also worries regulations and paperwork requirements are too strict for doctors and there is a risk more children will commit suicide if they are not treated with medication.

Still another concern is the use of off-label medications, which haven't been properly tested for children, said Howard Talenfeld, president of Florida's Children First, a statewide nonprofit children's advocacy group, and chairman of a Florida Bar committee looking at children's legal needs.

Ken Kramer, researcher for the Citizens Commission on Human Rights of Florida in Clearwater, which is associated with the Church of Scientology, agrees. He wants to see parents of all children fully informed about alternatives and risk and legislation requiring annual disclosures of gifts/payments by drug companies to physicians.

Walter Grimes' aunt did her homework, and even though psychotropic medication is helping Walter and one of his brothers, she hopes they won't have to take the medicine for very long.

"That is my prayer," she said. "They said they can wean them away from it if they get better. I look forward to the day they can be off the medicine."

State revamping children's medication rules

Christina Pooley was used to the morning, noon and night ritual.

She'd open her mouth and move her tongue around so workers could see that the psychotropic medication she picked up in a little cup with her name on it was gone.

She tried "cheeking" her meds by hiding them in her cheek or partly swallowing them and coughing them up in her room at therapeutic foster homes throughout the state. When staff caught on and she refused to take the medicine, she said they'd give it to her through a shot or crush it up in apple sauce and watch her eat it.

The now 21-year-old Holly Hill woman said throughout almost her entire stay in foster care, from age 13 to 18, she was prescribed several medications at a time for mental health diagnoses, including depression, bipolar disorder, borderline personality disorder and oppositional defiant disorder.

Pooley's story of being on psychotropic medications is not uncommon in foster care, state and national child welfare experts say. Nationally about 5 percent of all children are treated with psychotropic medications, but in foster care it ranges from 13 to 53 percent in states nationwide, experts say.

In Florida's foster care system on Jan. 4, for example, about 14.5 percent of children -- or 2,745 children -- received one or more medications. The numbers locally were 13.5 percent or 112 children.

The April 2009 death of a South Florida 7-year-old foster child, Gabriel Myers, who was prescribed several mind-altering drugs and hanged himself in his foster home, sparked a statewide review and new rules, and legislation is being developed.

Pooley admits she hit walls, threw things, cut herself on her inner arms and legs and ran from group and foster homes, spending days on the Boardwalk. But she also thinks she was overmedicated. She now receives individual therapy at Halifax Health Behavioral Services and said she's only on two medications to help her sleep.

Officials with the state Department of Children & Families would not comment on Pooley's time spent in foster care and her records are not public. But a work group has been studying the broader issue after the South Florida child's death last year .

The group made 90 recommendations in November, including hiring a chief medical officer to monitor prescribing such medications and appointing attorneys for children. Some changes have already been made, such as obtaining proper court and parental consent. DCF is continuing to develop new rules.

DCF Secretary George Sheldon said the state needs to ensure it's dealing with children's behavioral needs appropriately and realize just the act of removing children from their home is traumatic.

"I'm not anti-medication, but I think it is a last resort," Sheldon said.

Locally, child-welfare officials have trained caseworkers on new requirements, including ensuring parents understand the forms they sign, consenting to their children being placed on psychotropic medication.

Robin Rosenberg, who serves on a statewide DCF work group and is deputy director of Florida's Children First, a child advocacy agency, said the issue is whether the "right kids are getting the right medications."

"Before you say we are going to cure that problem with medicine, you need to address what is happening in that child's life," Rosenberg said.

Pooley said she was removed from her home and placed in the state's care because of issues at home. She also said each time she moved from one group home to the next, new doctors would put her on different psychotropic medications, which child-welfare officials and Halifax Health Behavioral Services representatives said is not unusual when children move around and see new doctors.

But Pooley said sometimes the amount of medication she was on made her feel "like I wanted to die." She said when she was 16, she tried overdosing on one of the medications -- Seroquel, which DCF officials say is the most common psychotropic drug used on local foster children.

When she ran from foster care and was on the Boardwalk, she said, she felt better being off medication.

She said that at Halifax Health Behavioral Services -- where she was taken by police under the state's Baker Act as being a danger to herself or others -- doctors took her off all her medications, evaluated her and put her on fewer medications. She believes the people there saved her life and are continuing to help her now with therapy since finding out two years ago she's going blind from a brain malformation that also causes headaches and insomnia.

"It's more depressing than being in foster care, but I don't act out or cut myself and I'm able to deal with it," Pooley said.

She's planning to start back this month at Daytona State College after various surgeries. She wants to get a degree in psychology and work with children at Halifax Health Behavioral Services.

"A lot of (other) people gave up and said I wasn't going to amount to anything," Pooley said. "But people at (Halifax Health Behavioral Services) said, 'We know you have it in you. This is what you have to work on and get it done.' They kind of held me to it."

deborah.circelli@news-jrnl.com

BY THE NUMBERS

Here are the number of children prescribed psychotropic medications to deal with the top four diagnoses at Halifax Health Behavioral Services:*

1,350 Children who are prescribed drugs, such as Concerta or Adderall, for attention-deficit hyperactivity disorder/attention-deficit disorder. Possible side effects are: anxiety, nervousness, chest pain, high blood pressure, headache and mood changes.

471 Children who are prescribed drugs, such as Prozac or Lexapro, for major depression/depressive disorder. Possible side effects are: nervousness; loss of appetite; anxiety or trouble sleeping; and feelings of irritability. May increase risk of suicidal thoughts in children, teens and young adults.

241 Children who are prescribed drugs, such as Depakote/Depakene, for bipolar disorder. Possible side effects are: dizziness; increased or decreased appetite; trouble sleeping; fast or irregular heartbeat; and hallucinations. Severe and sometimes fatal liver problems have occurred.

159 Children who are prescribed drugs, such as Seroquel, for oppositional defiant disorder. Possible side effects are: fast or irregular heartbeat; increased hunger; seizures; and suicidal thoughts or mood changes.

NOTE: *Number of children as of Dec. 11, 2009

SOURCE: Halifax Health Behavioral Services and News-Journal research

BAKER ACT & CHILDREN

The number of children in Volusia and Flagler counties admitted to Halifax Behavioral Services involuntarily under the state's Baker Act as a danger to themselves or others is on the rise:

2005/2006: 289

2006/2007: 662

2007/2008: 784

2008/2009: 845

SOURCE: Halifax Behavioral Services.

Fiscal year starts Oct. 1 and ends Sept. 30.

PSYCHOTROPIC MEDICATION IN FOSTER CARE

The number of children from birth to age 17 in foster care who are on one or more psychotropic medications:

· Florida: 2,745 children or 14.55 percent of all children in foster care.

· Volusia/Flagler/Putnam: 112 children or 13.58 percent of all children in foster care

SOURCE: Florida Department of Children & Families as of Jan. 4, 2010

http://www.news-journalonline.com/NewsJournalOnline/Lifestyle/Health/entHEAD03HEAL011010.htm