One Flew Over the Morning News

Dallas paper fails to connect industry influence to overmedication among foster children

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.

As my colleague Curtis Brainard here at The Observatory suggests, she might have done better turning her investigative skills on whether Texas foster kids are being over-medicated—a tough-enough story in itself. And if she discovered that was true, she could have reported on what might be done to correct the problem.

Or she might have confined herself to investigating the doctors treating these kids and their connections to drug companies. That, indeed, was the headline on the story: “Some Texas foster kids’ doctors have ties to drug firms.” Again, if she nailed that story, she could have followed up with reporting on what the state might do to confront that issue.

Ramshaw’s story, I fear, will leave most readers thinking that the vast majority of kids are being over-diagnosed and over-medicated by a greedy alliance of doctors and drug companies. There is no doubt that that happens. Drug companies are often far too aggressive in pushing their medications, to the detriment of patients, and doctors should not have such strong financial ties to drug companies.

Most mental health professionals, and the parents of mentally ill children, however, think that the problem is exactly the opposite: too many mentally ill kids are not getting the treatment they desperately need.

Reporters who venture into this territory cannot let heart-tugging anecdotes lead readers to faulty conclusions. We need to be acutely aware of the political and public policy debates into which our stories fall. Whether she intended to or not, Ramshaw has given lots of ammunition to critics who say we’re vastly over-medicating our kids. Fair enough, if the reporting backs it up. But in this case, the reporting falls short.

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Paul Raeburn is a journalist and broadcaster, and the author, most recently, of Acquainted with the Night, a memoir about raising children with depression and bipolar disorder. His stories appear in The Huffington Post, The New York Times Magazine, Scientific American, Technology Review, Psychology Today, and on his blogs, Fathers and Families and Psychology Today's About Fathers. Raeburn has been senior editor for science and technology at BusinessWeek, science editor at The Associated Press, and is a past president of the National Association of Science Writers.