Last Sunday, The Dallas Morning News ran what it called “an investigation” of the use of psychiatric drugs to treat foster children in Texas. The story started off with a bang, or several of them:
• One in three foster children in Texas has been diagnosed with a mental illness. Wham!
• Those kids have been prescribed “mind-altering” drugs—including some not approved by the federal government! Bam!
• The drugs are being prescribed by doctors with a financial stake in pharmaceutical companies’ success! Socko!
All three of these revelations occurred in the first two sentences. That’s taut writing, sure to grab a reader’s attention. Unfortunately, the overheated language and the lack of context in this story gives readers a distorted view of mental illness in children—and the way it’s treated (or mis-treated).
The article supports the widely held view that children are being over-diagnosed with mental illness, over-treated with dangerous drugs, and that this is happening because of financial collusion between doctors and drug companies. All of those things might be true—but the Morning News investigation does not make the case.
To her credit, the story’s author, Emily Ramshaw, does qualify her slam-bang lede. Accepting drug-company money is not illegal, she points out in paragraph three, and much of it has funded “groundbreaking scientific advances.” And she notes that financial ties between doctors and drug companies are often disclosed on Web sites, and in conference programs and journal articles.
But then she resumes her investigative zeal with a fourth charge. “Multiple drugs” were “being prescribed by doctors who weren’t psychiatrists or pediatricians,” she writes, some of whom “spent less than 10 minutes examining their young patients.”
I’ll raise some questions about these charges in a moment, and suggest what Ramshaw might have done differently to make this a first-rate story. But first, a word about one of Ramshaw’s anecdotes, guaranteed to reinforce the notion of wrongdoing, even though she herself reports that no wrongdoing was found.
The story, told in seven paragraphs, is of a twelve-year-old boy who died while being restrained in foster care. At the time of his death, he had four psychiatric drugs in his bloodstream. Ramshaw tells us that an autopsy found that his death was accidental—not related to the drugs. So why juxtapose these two observations? Are we to conclude that the autopsy was faulty? Ramshaw doesn’t say. And here’s the quote with which Ramshaw ends the anecdote: “He didn’t need any meds. He was the kind of kid who if someone had just threatened to call his mother, he probably would’ve stopped what he was doing I know Mikie and I didn’t need emotional stabilizers to save our lives.” The authority being quoted? Mikie’s teenage older sister.
Now back to Ramshaw’s powerfully delivered assertions.
1. One-in-three foster children in Texas has been diagnosed with a mental illness.
The implication is that this is very high; that healthy foster kids are being wrongly diagnosed with mental illness, and wrongly prescribed psychiatric drugs. But how high is it? Ramshaw acknowledges that foster children “have far higher rates of mental illness than the average child,” but she doesn’t clarify—or back up—the implication that the kids are being over-diagnosed. She should have said how common psychiatric diagnoses are among American children generally, and interviewed experts about whether they think Texas foster kids are being over-diagnosed.
2. The kids are being prescribed “mind-altering” drugs not approved by the federal government.
Note the hyperbolic language—“mind-altering” drugs, not the more neutral “psychiatric drugs.” And here’s an important contextual point Ramshaw leaves out: only a few psychiatric drugs have been approved for use in children. The federal government has little money for studies with kids, and drug companies don’t want to invest in that. If they can already sell unapproved drugs to kids, why should they risk a study that might find problems and eliminate that lucrative market? The use of unapproved drugs in kids is a serious problem; but the alternative for many kids, Ramshaw should have said, is no drugs, even for kids who clearly are suffering.
3. The drugs are being prescribed by doctors with a financial stake in pharmaceutical companies’ success.
Again, note the strong language. Does a doctor who is paid for a talk have a stake in a company’s financial success? That’s going a little too far. Ramshaw reports that drug company money has funded breakthrough research, but she doesn’t make clear that in the absence of that money, the research wouldn’t be done. It’s right to question research supported by drug companies—but she should have noted that in many cases there is no alternative.
4. Drugs are sometimes being prescribed by doctors who aren’t psychiatrists or pediatricians.
First, let’s dispense with pediatricians. Their training includes only the briefest exposure to psychiatry, if they have any exposure to it at all. Ramshaw is right—drugs should be prescribed by child psychiatrists, who are the experts. She fails to note that there are about 7,000 child psychiatrists in the United States—one for every 750 American children with severe mental illness. If other doctors didn’t prescribe psychiatric drugs to children, then most mentally ill children who need them wouldn’t get them. And we could have used more information—perhaps in a sidebar—about what doctors are prescribing medicine to foster kids. She is right about one thing: no doctor should prescribe these drugs after only ten minutes with the patient.
Ramshaw clearly did extensive reporting for this piece, and it had the makings of a first-rate investigation. It failed, I think, because she tried to tackle too many things—the poor treatment of foster children in Texas, questions about the misuse of psychiatric drugs by unskilled doctors, a suspect financial relationship between doctors and drug companies, and questions about the FDA’s drug-approval process for kids.
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What’s unfortunate about Paul Raeburn’s criticism of my series is that he casts aside a central tenet of the story: It’s about Texas foster children, not all children.
These are kids who often don’t have a parent looking out for their best interests. In a system where foster parents get paid more for kids with particularly troublesome diagnoses, and many doctors are on drug company payrolls, the sense is that there’s little incentive to take a conservative approach to prescription.
Raeburn’s critique of my story includes passages he took out of context, including the anecdote he references about a little boy who died in state foster care. That story was about the little boy’s older sister (no longer a teenager) who was undoubtedly drugged into a near stupor for years while herself in foster care. The death of this young woman’s brother – and the irony that both of them were, for the first time in their lives, on several psychiatric drugs at once -- only compounds her tragedy.
As to Raeburn’s beef with the “high” percentage of foster kids treated with psychiatric drugs: Yes, I agree. It would have been lovely to say with authority the X percent of U.S. kids are on psychiatric meds. But Raeburn knows as well as I do that these numbers don’t exist, which is why I included the best numbers available – from a national pharmaceutical study. They appear to be far lower than the 1 in 3 Texas foster care average, though Raeburn either missed that paragraph or chose to ignore it.
Raeburn asserts that these doctors don’t necessarily have a stake in drug companies’ success. What, then, constitutes a stake? Many doctors are awarded stock options – which are useless if drug companies fail. And I don’t know of many drug companies that offer lucrative consulting contracts while they’re circling the drain.
Finally, I agree with Raeburn that the U.S. isn’t flush with child psychiatrists. But that doesn’t mean that radiologists and gastroenterologists should be the ones deciding whether Texas foster kids should be taking psychiatric drugs.
Raeburn takes my story about a particular group of children – Texas foster kids – and extrapolates it to a giant population: all children.
Raeburn knows his stuff. And as I told him yesterday, I'm always up for a good skewering. But it’s less fun when someone with a personal sensitivity to an issue puts words in your mouth.
Emily Ramshaw
Posted by Emily Ramshaw on Thu 21 Aug 2008 at 05:06 PM
I can attest to the fact that far too many foster kids are taking far too many psychotropic medications. I've noted it in the short period of time I've been a witness, and pointed it out to my collegues who generally agree. What's to be done? I don't know. What I do know is that when a six year old girl is taking Risperdal, Adderall, Stratera, and several other medications during the day and diphenhydramine at night to sleep, something isn't right.
Kids in foster care are screwed up before they ever get there in a lot of cases. However, no one is served by drugging them through life.
Posted by Sarah on Thu 21 Aug 2008 at 11:06 PM
All across the country, child "protective" services do all in their (substantial) power to pressure both parents and children onto psychiatric drugs. The pharmaceutical industry is the number one profit-making industry in the country. Everything you hear about psychiatry and "mental illness" is a lie. Read Peter Breggin, John Breeding, Robert Whitaker, to name a few. We all have difficulties because how we've been hurt, and what we really need is love and caring and emotional healing. But if you don't have the ability to question the concepts on which the institutions of this society are built, or to question your own assumptions and biases, then you don't want to know.
Posted by Connie Schuster on Thu 21 Aug 2008 at 11:25 PM
Mr. Raeburn is, if anything, being too kind in his evaluation of Ms. Ramshaw's hyperbolic and misleading reporting in the Dallas Morning News.
While there are significant problems with the relationship between the pharmaceutical industry and clinical practitioners, stating that these doctors are "on the payroll" of the pharma companies conjures up Hollywood-style images of corrupt cops. The statement that "many doctors are awarded stock options" is ludicrous on its face. (Some physicians involved in developing a new drug may be offered options, but these are a tiny minority of those who write prescriptions.)
Similarly, stating that researchers get grants that "often exceed $100,000" immediately after describing the honoraria for giving a presentation at a professional meeting or symposium implies that the $100,000+ represents income to the physician. While a fraction of it might be taken as income, the bulk of it goes to pay for the expenses of conducting the studies. (Yes, there are issues with pharma company involvement in clinical research, but with the dramatic decline in the availability of federal funds, researchers are faced with fewer choices when it comes to funding. There are stories to be done there, but this one isn't it.)
Off-label prescribing, which she refers to misleadingly as "without federal approval," is a function of the FDA regulations for drug testing and the economics of testing drugs for multiple uses. Yet the tone of her description wrongly hints at nefarious doings.
Inappropriate polypharmacy--the use of multiple psychiatric drugs simultaneously--is an ongoing issue. But the response shouldn't be a knee-jerk abandonment of all psychiatric medications on children. Nor should we take an older sister's or a mother's appraisal of the lack of need for medication as unbiased or the gospel truth.
The list goes on. It was a missed opportunity for effective public education that will likely have unintended negative consequences.
Posted by Lawrence Kutner, Ph.D. on Fri 22 Aug 2008 at 04:17 PM
My son, Evan Kitchens, was one of the children mentioned in Emily's report. I am thankful for her reporting and quite honestly Dr. Kutner, I pray that her well researched reporting does have negative consequences. I am sure that you were directing your comment on "negative consequences to what you think are benefits to children in Foster Care. I, on the other hand, and refering to the consequences that should be and will soon be imposed on the doctors and Drug Companies.
The numbers are there to support her findings. Her report was based on FACT. My only regret about the report was that it did not paint a better picture for the readers to understand just how drugged these children are.
While the "Great State of Texas" had custody of my son, he was on more medication than what was recommended for an adult. How can someone, much less a doctor, justify that? I saw children so medicated in these facilities that they could not even carry on a conversation. Their words were unclear, eyes glazed over, no affect, afraid to interact with adults...you tell me...HOW CAN THAT BE JUSTIFIED?
I want to tell you just exactly what my "unbiased gospal truth" is based on. When I got Evan back and took him off of all the drugs that he was given, I saw a child that I had never seen. Within 1 year, he was on the honor roll at school. He began to interact with peers. His communication bloomed and then he began to share with me his experiences in RTC's. They are horrific and I hope that you, as a parent, will never have to hear the stories he tells. Stories of DOCTORS ordering him into the quiet room and taking his clothing away, leaving him with only a mattress, pillow and a paper gown for 3 (yes, I said THREE) days. Not allowing me to see him, no contact with anyone that was not an employee of the hospital. After finally getting an emergency order from a judge to get him out of issolation, did they tell me their logic behind this abuse. I quote "When you strip a child of their dignity, they will comply to gain it back". All of this because he refused to go to bed. Evan's medical records reflect that he had been for weeks (yes, i said WEEKS) telling DOCTORS that he was being sexually abused by another resident and the DOCTORS did not believe him. They noted in his records that they thought he was having dreams. It was not until other children told those very doctors that they had witnessed the sexual abuse.
My son has Autism. I, like yourself, realise that Autism poses a huge challenge on famlies. Evan was never the victom of abuse until I took him to doctors, despirate to find solutions and respite for my other children. That is what mothers do. We trust (in my case, trusted) doctors to help us find the right path for Evan. All we ever got were pills. I have a huge amount of samples that were given to us by PEDIATRIC PSYCS! Samples (54 to be exact) of Seroquel. How is it that they jsut have samples laying around by the case! If the AstraZeneca does not recommend the use of Seroquel in children, then how did the Pediatric Psyc get those samples. How did he get the toys "Seroquel" printed on them in his office. I would like to hope that AstraZeneca has a catalog that docs can purchase these items out of, but I have yet to find one. You and I both know that they are handed out by Reps, there for one purpose. The more that prescribes thier med, the more they make.
All of that being said, I still say there is more to this.....
Can you think of a more captive market for testing drugs than Foster Care? I once asked one of the nurses at Laurel Ridge Hospital what Evan was on after I noticed they had drawn his blood. she replied....Seroquel. I asked her to tell me what she knows about it and she said..."not much, I jsut know that I give it to all the kids here..some get more and some get less, but they all get it.
I would really like to know, Dr. Kutner, if you would take the time to answer this extremely bias mother, JUST HOW DO YOU JUSTIFY THAT?
Mary Kitchens
Posted by Mary Ktchens on Thu 4 Sep 2008 at 01:27 AM