Off-Label Use Of Risky Antipsychotic Drugs Raises Concerns

By Sandra G. Boodman

Adriane Fugh-Berman was stunned by the question: Two graduate students who had no symptoms of mental illness wondered if she thought they should take a powerful schizophrenia drug each had been prescribed to treat insomnia.

"It's a total outrage," said Fugh-Berman, a physician who is an associate professor of pharmacology at Georgetown University. "These kids needed some basic sleep [advice], like reducing their intake of caffeine and alcohol, not a highly sedating drug."

Those Georgetown students exemplify a trend that alarms medical experts, policymakers and patient advocates: the skyrocketing increase in the off-label use of an expensive class of drugs called atypical antipsychotics. Until the past decade these 11 drugs, most approved in the 1990s, had been reserved for the approximately 3 percent of Americans with the most disabling mental illnesses, chiefly schizophrenia and bipolar disorder; more recently a few have been approved to treat severe depression.

But these days atypical antipsychotics -- the most popular are Seroquel, Zyprexa and Abilify -- are being prescribed by psychiatrists and primary-care doctors to treat a panoply of conditions for which they have not been approved, including anxiety, attention-deficit disorder, sleep difficulties, behavioral problems in toddlers and dementia. These new drugs account for more than 90 percent of the market and have eclipsed an older generation of antipsychotics. Two recent reports found that children and adolescents in foster care, some less than a year old, are taking more psychotropic drugs than other children, including those with the severest forms of mental illness.

In 2010 antipsychotic drugs racked up more than $16 billion in sales, according to IMS Health, a firm that tracks drug trends for the health-care industry. For the past three years they have ranked near or at the top of the best-selling classes of drugs, outstripping antidepressants and sometimes cholesterol medicines. A study published last year found that off-label antipsychotic prescriptions doubled between 1995 and 2008, from 4.4 million to 9 million. And a recent report by pharmacy benefits manager Medco estimated that the prevalence of the drugs' use among adults ballooned more than 169 percent between 2001 and 2010.

Critics say the popularity of atypical antipsychotics reflects a combination of hype that the expensive medicines, which can cost $500 per month, are safer than the earlier generation of drugs; hope that they will work for a variety of ailments when other treatments have not; and aggressive marketing by drug companies to doctors and patients.

"Antipsychotics are overused, overpriced and oversold," said Allen Frances, former chair of psychiatry at Duke University School of Medicine, who headed the task force that wrote the DSM-IV, psychiatry's diagnostic bible. While judicious off-label use may be appropriate for those who have not responded to other treatments for, say, severe obsessive-compulsive disorder, Frances said the drugs, which are designed to calm patients and to moderate the hallucinations and delusions of psychosis, are being used "promiscuously, recklessly," often to control behavior and with little regard for their serious side effects. These include major, rapid weight gain -- 40 pounds is not uncommon -- Type 2 diabetes, breast development in boys, irreversible facial tics and, among the elderly, an increased risk of death.

The Latest Fad?

Doctors are allowed to prescribe drugs for unapproved uses, but companies are forbidden to promote them for such purposes. In the past few years major drugmakers have paid more than $2 billion to settle lawsuits brought by states and the federal government alleging illegal marketing; some cases are still being litigated, as are thousands of claims by patients. In 2009 Eli Lilly and Co. paid the federal government a record $1.4 billion to settle charges that it illegally marketed Zyprexa through, among other things, a "5 at 5 campaign" that urged nursing homes to administer 5 milligrams of the drug at 5 p.m. to induce sleep.

Wayne Blackmon, a psychiatrist and lawyer who teaches at George Washington University Law School, said he commonly sees patients taking more than one antipsychotic, which raises the risk of side effects. Blackmon regards them as the "drugs du jour," too often prescribed for "problems of living. Somehow doctors have gotten it into their heads that this is an acceptable use." Physicians, he said, have a financial incentive to prescribe drugs, widely regarded as a much quicker fix than a time-intensive
evaluation and nondrug treatments such as behavior therapy, which might not be covered by insurance.

In a series in the New York Review of Books last year, Marcia Angell, former editor in chief of the New England Journal of Medicine, argued that the apparent "raging epidemic of mental illness" partly reflects diagnosis creep: the expansion of the elastic boundaries that define mental illnesses to include more people, which enlarges the market for psychiatric drugs.

"You can't push a drug if people don't think they have a disease," said Fugh-Berman, who directs PharmedOut, a Georgetown program that educates doctors about drug marketing and promotion. "How do you normalize the use of antipsychotics? By using key opinion leaders to emphasize their use and through CMEs (continuing medical education) and ghost-written articles in medical journals," which, she said "affect the whole information stream."

James H. Scully Jr., medical director of the American Psychiatric Association, sees the situation differently. He agrees that misuse of the drugs is a problem and says that off-label prescribing should be based on some evidence of effectiveness. But Scully suggests that a key factor driving use of the drugs, in addition to "intense marketing and some effectiveness," is the growing number of non-psychiatrists prescribing them. Many lack the expertise and experience necessary to properly diagnose and treat mental health problems, he said.

Among psychiatrists, use of antipsychotics is rooted in a desire to heal, according to Scully. "All of the meds we use have their limits. If you're trying to help somebody, you think, 'What else might I be able to do for them?' "

Since 2005, antipsychotics have carried a black-box warning, the strongest possible, cautioning against their use in elderly patients with dementia, because the drugs increase the risk of death. In 2008 the Food and Drug Administration reiterated its earlier warning, noting that "antipsychotics are not indicated for the treatment of dementia-related psychosis." But experts say such use remains widespread.

In one Northern California nursing home in 2006 and 2007, 22 residents, many suffering from dementia, were given antipsychotics for the convenience of the staff or because the residents refused to go to the dining room. In some cases the drugs were forcibly injected, state officials said. Three residents died.

A 2011 report by the inspector general of the Department of Health and Human Services found that in a six-month period in 2007, 14 percent of nursing home residents were given antipsychotics. In one case a patient with an undetected urinary-tract infection was given the drugs to control agitation.

"The primary reason is that there's not enough staff," said Toby S. Edelman, senior policy attorney for the Center for Medicare Advocacy, a Washington-based nonprofit group, who recently testified about the problem before the Senate Special Committee on Aging. "If you can't tie people up, you give 'em a drug" she said, referring to restrictions on the use of physical restraints in nursing homes.

Drugs At 18 Months

Nursing home residents aren't the only ones gobbling antipsychotics.

Mark E. Helm, a Little Rock pediatrician who was a medical director of Arkansas's Medicaid evidence-based prescription drug program from 2004 to 2010, said he had seen 18-month-olds being given potent antipsychotic drugs for bipolar disorder, an illness he said rarely develops before adolescence. Antipsychotics, which he characterized as the fastest-growing and most expensive class of drugs covered by the state's Medicaid program, were typically prescribed to children to control disruptive
behavior, which often stemmed from their impoverished, chaotic or dysfunctional families, Helm said. "Sedation is the key reason these meds get used," he observed.

More than any other factor, experts agree, the explosive growth in the diagnosis of pediatric bipolar disorder has fueled antipsychotic use among children. Between 1994 and 2003, reported diagnoses increased 40-fold, from about 20,000 to approximately 800,000, according to Columbia University researchers.

That diagnosis, popularized by several prominent child psychiatrists in Boston who claimed that extreme irritability, inattention and mood swings were actually pediatric bipolar disorder that can occur before age 2, has undergone a reevaluation in recent years. The reasons include the highly publicized death of a 4-year-old girl in Massachusetts, who along with her two young siblings had been taking a cocktail of powerful drugs for several years to treat bipolar disorder; the revelation of more than $1 million in unreported drug company payments to the leading proponent of the diagnosis; and growing doubts about its validity.

Helm said that antipsychotics, which he believes have become more socially acceptable, serve another purpose: as a gateway to mental health services. "To get a child qualified for SSI disability, it is helpful to have a child on a medicine," he said, referring to the federal program that assists families of children who are disabled by illness.

Ask Your Doctor

Psychiatrist David J. Muzina, a national practice leader at pharmacy benefits manager Medco, said he believes direct-to-consumer advertising has helped fuel rising use of the drugs. As former director of the mood disorders center at the Cleveland Clinic, he encountered patients who asked for antipsychotics by name, citing a TV commercial or print ad.

Some states are attempting to rein in their use and cut escalating costs. Texas has announced it will not allow a child younger than 3 to receive antipsychotics without authorization from the state. Arkansas now requires parents to give informed consent before a child receives an anti-psychotic drug. The federal Centers for Medicare and Medicaid Services announced it is summoning state officials to a meeting this summer to address the use of antipsychotics in foster care. And Sens. Herb Kohl (D-Wis.) and Charles E. Grassley (R-Iowa) introduced legislation that would require doctors who prescribe antipsychotics off-label to nursing home patients to complete forms certifying that they are appropriate.

Medco is asking doctors to document that they have performed diabetes tests in patients taking the drugs. "Our intention here is to get doctors to reexamine prescriptions," Muzina said.

"In the short term, I don't see a change in this trend unless external forces intervene."

Source http://www.kaiserhealthnews.org/Stories/2012/March/13/off-label-use-of-risky-antipsychotic-drugs.aspx

Foster Kids Prescribed Psychotropic Drugs - ABC's 20/20 - Aired 12-01-2011

Blogger note:
This is a very good report but for the fact that it doesn't address anything to do with some children have no reason to be in foster care and that they have willing and able parents or relatives to take care of them but CPS forces the children to stay in foster care. Even so, the basic message of the expose is quite informative about the misuse of psychotropic drugs on foster children.
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Doctor at Austin State Hospital accused of child sex abuse - Texas

By Andrea Ball and Eric Dexheimer

The state Department of Family and Protective Services has accused a longtime staff child psychiatrist for the Austin State Hospital of sexually abusing at least one child in his care, and investigators from an independent oversight agency have opened a wider inquiry into accusations from at least eight possible victims dating back a decade.

The state agency alerted hospital officials three weeks ago that it had confirmed that Dr. Charles Fischer had been involved in two separate instances of sexual abuse, said Patrick Crimmins, a spokesman for the agency. The agency terms an incident "confirmed" if its investigation shows the allegation is supported by a preponderance of the evidence.

Carrie Williams, a spokeswoman for the Department of State Health Services, which runs the Austin hospital, said Fischer, 59, was fired effective Monday.

The state hospital is a residential facility for people with mental illness. The child and adolescent unit where Fischer worked houses youths up to the age of 18. The Adult Protective Services division of the Department of Family and Protective Services is required by law to investigate allegations of abuse and neglect in state hospitals.

Crimmins said police have been notified of the agency's findings; however, an Austin police spokeswoman said Fischer has not been charged with any crimes.

Contacted at his West Lake Hills home, Fischer declined to comment. "You'll have to ask the hospital about that," he said.

The Texas Medical Board, which licenses physicians, shows Fischer has an unblemished disciplinary record. Details of the case against Fischer were still unclear late Wednesday. Williams did not say when the two confirmed incidents occurred, how they were confirmed, if the youth was a boy or a girl, or whether he or she was still a hospital resident.

But, she said, Fischer, who earned $185,000 a year from the state, had been accused of sexually abusing patients in the past.

"There were previous allegations against Dr. Fischer over the years," she said. "Each was reported and investigated outside the agency, but the allegations were never confirmed."

Crimmins said the Department of Family and Protective Services investigated each of the abuse allegations as they became known.

"We have received several reports alleging sexual abuse by Dr. Charles Fischer dating back several years. In each instance in which sexual abuse by Dr. Fischer was alleged, law enforcement was notified at the time of the initial report, and again when a finding was made," he wrote in an email response to questions.

"Each case was investigated thoroughly, but none were confirmed until October, when two separate allegations of sexual abuse against Dr. Fischer were confirmed, and the Department of State Health Services was notified."

A spokeswoman for the state Health and Human Services Commission said the agency's internal investigative arm was looking into the abuse allegations. Stephanie Goodman declined to say whether the Office of Inspector General was investigating the incidents of alleged abuse or the agency's response to them.

And on Wednesday, Disability Rights Texas — a nonprofit organization officially designated by the federal government to protect the rights of the state's disabled — said it had launched an inquiry into cases involving eight potential victims in incidents involving Fischer dating back to 2001. Because of its federal affiliation, the organization has access to records at state hospitals and can bring lawsuits against the state on behalf of people with disabilities.

Beth Mitchell, an attorney for the organization, said she did not yet know if the eight cases it had been notified of included the two abuse incidents confirmed by the Department of Family and Protective Services.

"We are all heartbroken over these allegations," Williams said. "These kids come to us to heal, and the situation is very sad and extremely troubling for everyone involved."

State records show Fischer received his medical license in 1978 from the University of Texas Health Science Center in San Antonio. He completed a residency in general psychiatry and further specialized training in child psychiatry, the records show.

http://www.statesman.com/news/local/doctor-at-austin-state-hospital-accused-of-child-1974447.html

L.A. County health official's dual roles are questioned

Child welfare agency medical director Dr. Charles Sophy also has a private practice where he works on such reality TV shows as 'Real Housewives of Beverly Hills.'

By Amy Kaufman and Garrett Therolf, Los Angeles Times

September 2, 2011, 5:45 p.m.

Dr. Charles Sophy, medical director for Los Angeles County's beleaguered child welfare agency, carries two cellphones in his pocket.

One BlackBerry tethers him to his county job, where he is responsible for the mental health needs of nearly 20,000 foster children. The second — kept in a plastic case adorned with images of dollar bills — is reserved for his Beverly Hills-based private psychiatric practice, where his patients have included Paris Hilton, and for scheduling appearances on television interview and reality shows. Among his recent on-camera sessions was counseling of "Real Housewives of Beverly Hills" cast member Taylor Armstrong and her husband, Russell, before Russell Armstrong committed suicide Aug. 15.

The two phones, Sophy said, signal his commitment to strictly segregate his public and private worlds. Despite those efforts, the two roles have overlapped in ways that have attracted attention.

Some say the county is fortunate to have a nationally recognized mental health expert on staff and that Sophy has made significant improvements in foster child care. But others argue that he has grown gradually more distracted over the years, and they question his commitment to the $256,000 county post.

"He's a guy who is preoccupied. I think the county comes second. Why is he involved in all this outside work when he has a house that is not in order at DCFS?" asked Aubrey Manual, president of a local foster parent association.

Sophy and the executive team in charge of the Department of Children and Family Services have come under repeated criticism for systemic breakdowns that contributed to the fatalities of children under their supervision. Sophy's unit has been specifically faulted in some of those deaths, and Supervisor Gloria Molina harshly scolded him in a closed-door meeting this year, according to officials familiar with the exchange.

Specifically, the department has been faulted for slow progress implementing a legal settlement that requires it to dramatically improve care for thousands of mentally ill children requiring intensive treatment.

Yet Sophy still enjoys high regard among many in the child welfare community, and he said county officials recently asked him to apply to lead the agency. Even some of the agency's most trenchant critics praise him.

Kim Lewis, the lead plaintiff attorney in the class action against the county, said Sophy has been an effective partner. Furthermore, she said it was important that Sophy is the longest-serving member in the agency's management team, a group notorious for its revolving door.

"I think he is one of the few folks who brings a sense of continuity to the important issues, and I think he has shown himself to care significantly about the issues and the kids," Lewis said. "I think he is an advocate for change."

Sophy, 50, maintains that he gets more out of helping the underprivileged than the rich and famous, pointing to his own background as the son of a Pennsylvania coal miner as evidence of his connection to hard-scrabble life. He earned his medical degree from the Philadelphia College of Osteopathic Medicine, worked as a psychiatrist for the county Department of Mental Health and has been medical director since 2003.

"Honest to God, this is where my heart is," Sophy said in his government office, where the walls are covered with diplomas, children's artwork and photos of his 9-year-old son. "I put it all into perspective. There are many times I go to see my patients in 90210 and I'm like, 'Do you have any idea that I was just in a home where they didn't have dinner?'"

Sophy, who has a personal publicist who promotes him to various news outlets, has devoted a growing portion of his time to his more glamorous endeavors. This year alone, he has appeared on nearly 20 news programs, including 11 appearances on NBC's "Today" show.

In 2007, he took extended lunch breaks from his county job to visit Hilton in jail and meet with sheriff's officials to tell them that the Lynwood lockup was imperiling her mental health. Sophy said the trips were approved by Trish Ploehn, the agency's director at the time.

The same year, Sophy frequently appeared on TV as an expert commentator on the case of Nadya Suleman, the Whittier woman who gave birth to octuplets after treatment by a fertility physician.

Suleman's situation caused numerous calls to the county's child abuse hotline, and department officials say they are strictly barred from speaking about such cases.

Nevertheless, Sophy went on CNN's "Larry King Live" to offer his opinion on Suleman. "I think it's an outrageous number of children," he said.

Sophy said he believed the interview did not pose a conflict of interest, because the department had not initiated a formal investigation of Suleman in L.A. County.

Many of Sophy's television interviews in the last year supported a 2010 book he co-wrote about mother and daughter relationships that received glowing endorsements from Hilton, actress Sharon Stone and Dr. Drew Pinsky, host of "Celebrity Rehab With Dr. Drew." In 2008, Sophy began appearing on episodes of Pinsky's VH1 program about stars facing serious addiction issues. He has done a variety of other consulting work for reality television — most of which, he said, he is not paid for.

"When I'm on these shows, I go back to — 'No, this is about teaching. This is about breaking the stigma. This is about treatment,'" Sophy said. "These shows can be helpful, and you can watch and project your own issues on them and learn how to navigate problems."

But Dr. Paul Root Wolpe, director for the Center for Ethics at Emory University, questioned if it's in the best interests of patients to broadcast their therapy.

"The nature of therapy suggests that there are things people don't know about themselves that they need to reveal, so how can one truly consent to having that process filmed when one doesn't really know what they'll end up saying?" Wolpe questioned. "The highest standards of medical ethics would say you don't put someone in that risky a situation."

Last year, Sophy said, he was in discussions with ABC to host two reality shows, but they "never really panned out." Instead, he has devoted time to teaching at USC, Pierce College and UCLA, and he does occasional national paid speaking engagements across the country.

"If he is out of town, we are usually told," said Lisa Mandel, an aide to Supervisor Zev Yaroslavsky. "Wherever he goes, he's accessible. If I need him at 10 at night, I can call him."

That sentiment was echoed by one of Sophy's private patients, Melanie Brown, a former Spice Girl who has been working with him for more than three years.

"I could email him or call him right now, and he'd been on the phone in five minutes," said Brown, who once featured therapy sessions with Sophy on her reality show, "Mel B: It's a Scary World." "If I'm having a difficult time, no matter where he is in the world, no matter where I am — he's there for me."

In a statement of economic interest provided to the county, Sophy said his outside employment generated $10,001 to $100,000 last year. He also said he complies with a county policy that limits employees to 24 hours of outside work per week.

Sophy — whose everyday uniform consists of a well-tailored suit and dress shoes, sans socks — lives in a Beverly Hills home whose value was assessed at $3.5 million in 2007. He also owns two smaller properties in Rancho Mirage.

Although the Armstrong suicide focused renewed attention on Sophy's private practice, Sophy declined to comment on his relationship with the couple, citing physician-patient confidentiality. A person close to the production, requesting anonymity because they were not authorized to talk to the press, confirmed that Sophy's session with the Armstrongs were filmed.

It's not clear how much of that will appear on the new season of "Housewives," which debuts Monday on Bravo.

Source http://www.latimes.com/entertainment/news/la-et-0903-housewives-sophy-20110903,0,1633858.story

Adoption, Thow Away Kids, Money and CPS

When adoption goes wrong
Giving up custody to get kids the mental health care they need
By Patrick Yeagle

Wally and Dawne Busch of Petersburg eagerly adopted their son Alan at the age of two in 2000, knowing that they would be in for some challenging times. They knew that Alan, now 13, had been abused by his biological mother, and they weren’t surprised when, around the time he hit puberty, he began to develop severe emotional and behavioral issues, which often manifest in violent outbursts, threatening Alan’s safety and that of everyone around him.

He threatened to kill other children at school, threatened to hurt the couple’s other children, mutilated his own body and talked often about killing himself. But the Buschs say their most troubling challenge hasn’t been Alan’s behavior. It has been trying to help their son in an environment that they say pushes families to give up custody of children to the state in return for mental health services.

The Buschs adopted Alan and his sister, Stephanie, with assurances from DCFS that the state would pay for the children’s medical needs, including mental health care. Despite counseling and therapy, Alan’s behavior became too dangerous for the family to keep him in their home, according to Wally Busch, so in October 2010 the family had Alan committed to a short-term psychiatric hospital with plans to send him to a long-term residential care facility at his psychiatrist’s recommendation. Lacking the hundreds of thousands of dollars needed to pay for Alan’s treatment, the Buschs approached DCFS about paying for long-term care, but the agency declined.

After Alan spent a week in the psychiatric hospital, the Buschs received a call saying he was ready to come home – that he was no longer a danger to himself or others. Fearing for the safety of their family and of Alan himself, the Buschs took their attorney’s advice and decided not to pick Alan up from the psychiatric hospital. DCFS charged them with neglect, classifying the Buschs’ choice as a “psychiatric lockout.”

The neglect charge against the Buschs was dismissed in court, but their choice to not bring Alan back home essentially meant they had given up custody of Alan to the state. He remains in state custody at a residential treatment facility, though the Buschs retain parental rights such as visitation.

Custody relinquishment
The Buschs’ story is typical of a situation called custody relinquishment. It involves an adoptive family becoming overwhelmed by the challenges of a mentally ill or emotionally disturbed child. Usually after trying several methods of counseling and therapy that don’t seem to work, the family decides that expensive long-term residential care is the only option left, but securing funding from the state proves difficult or impossible. The family then decides the only option to secure treatment for the child is leaving him or her in the hands of the state. The decision to “lock out” a child usually comes at the suggestion of a family’s attorney, psychiatrist, or even a state agency, but it often results in the family losing custody of the child.

It’s difficult to tell how many custody relinquishments happen each year, but statistics on psychiatric lockout seem to indicate a worsening problem. Screening, Assessment and Support Services (SASS), a division of the Illinois Department of Human Services, says in an internal report that the number of psychiatric lockouts statewide more than tripled from 30 in 2003 to 104 in 2010. The Community and Residential Services Authority (CRSA), a state agency which guides parents through the maze of child welfare services when they have trouble, indicates in its 2009 and 2010 annual reports that custody relinquishment happens frequently enough to be a significant concern.

“Parents who attempt to access services through lockout in many instances end up relinquishing guardianship to the state and are often treated systemically as abusive or neglectful parents,” CRSA notes in its 2009 report. “CRSA staff do not believe that lockout is an effective mechanism for service planning and the CRSA board has long believed that parents should not be forced to give up guardianship and parental rights to their children simply to get their service needs met.”

The reports note that “referral to CRSA often implies a breakdown or a gap somewhere in the state service system.” CRSA cases increased from 355 in 2009 to 374 in 2010, with about half of cases from both years coming from families seeking residential care for a child with severe emotional disturbances or behavioral disorders. Of CRSA’s 355 cases in 2009, 32 came from Sangamon County.

John Schornagel, executive director of CRSA, which is based in Springfield, says custody relinquishment cases are the ones that “fall through the cracks” between the services offered by the half-dozen child-serving state agencies, including those that provide post-adoption services.

“I wish lockouts didn’t happen,” Schornagel says. “As a group of agencies and as a state, we need to find a solution to custody relinquishment. Certainly, DCFS has a good clinical division, and they’re capable of handling adopted kids who are at risk for adoption disruption. But for parents to have to go through the living hell of abandoning their kids to the system simply to get their mental health needs met is just the wrong way to go. There must be a better way.”

Schornagel says that of the more than 10,000 cases CRSA has handled in its 26-year existence, only 44 have required the CRSA board to step in and issue non-binding recommendations to resolve a conflict between state agencies and adoptive parents seeking services. Most cases get resolved before they get to the psychiatric lockout stage, Schornagel says, adding that many conflicts can be resolved if parents contact his agency for help securing services before a psychiatric lockout ever becomes an option.

CRSA reports identify other issues that hinder families’ efforts to obtain state services for mentally ill or emotionally disturbed children, including a lack of services available in a geographic area, state agencies deflecting clients to other agencies, ever-changing diagnostic criteria that require constant changes to services and programs, and the inability of schools to pay for appropriate educational plans for children with special needs.

Schornagel says the custody relinquishment problem is largely the result of changes made to DCFS in the 1990s because of a federal court order that required DCFS to put foster children into permanent homes within two years of entering the foster care system. He says “disrupting adoptions” will continue as long as there is such a short time frame for getting kids into permanent homes, combined with parents who “aren’t fully prepared and trained for the clinical kinds of challenges they’re going to face” when adopting.

Kendall Marlowe, spokesman for the Illinois Department of Children and Family Services, says the majority of adoptions do not result in custody relinquishment. He notes that Illinois had nearly 52,000 children in its foster care system in 1997, but that number has been reduced to fewer than 17,000 currently, mainly due to increased efforts to place foster children into permanent adoptive homes. About 26,800 children in Illinois receive a monthly adoption subsidy from the state, which Marlowe says is probably the best available estimate of currently adopted kids in Illinois – excluding adoptions done through private agencies.

About 99 percent of adoptions remain stable after two years, with 95 percent remaining stable after five years, according to a DCFS report.

Speaking generally and not about any specific case, Marlowe says long-term residential treatment like that sought by the Buschs is usually reserved for only the most mentally ill children. DCFS received 75 requests for residential placements in 2009, he says, and only seven of those cases received approval from DCFS director Erwin McEwen.

Many of the problems exhibited by adopted kids are common to all kids, Marlowe notes.

“Adoptive families are not the only families that struggle when kids move into adolescence, and many of the behaviors we associate with mental health conditions are very common among adolescents, including issues of sexuality, identity and attachment,” Marlowe says. “It can be too easy at times to perceive an adolescent’s struggle with maturity to be indicative of mental health conditions. Often, even when elements of mental health conditions are present, the more effective solution is therapy and intervention which involves the entire family. … Families often don’t want to hear that the entire family needs to be a part of the solution.”

Addressing the charge of neglect that often follows a psychiatric lockout, Marlowe says DCFS procedures call for an automatic neglect charge after any lockout, but the charge is usually only upheld if “the family is not engaged in coming up with a solution” for the child to return.

Schornagel says the proactive solution to custody relinquishment would be better community-based support services like intensive therapy and counseling in a child’s own community. Community-based services keep children in a familiar environment – usually their own home – while costing the state less money than residential treatment and pre-empting many of the problems that lead to psychiatric lockouts.

While many state agencies are working to establish more community-based services, Schornagel says that process requires diverting money away from things like residential care, which deals with kids who are already in crisis.

“My perception, from where I sit, is that community-based services aren’t available in the quantity or the quality that are necessary to maintain a lot of these kids, and that’s why it all breaks down,” Schornagel says. “All of the agencies that I’ve worked with have been, over the years, trying to back away from residential placement and take some of the money they were spending on residential care and redirect that to community-based programs. It’s a slow process of moving the money from the back end to the front end, and I think we’re in the middle of that.”

Marlowe says more community-based services are a big part of the solution, but families must also be prepared for the challenges they will face when adopting.

“All of us in the field believe that if we build a stronger safety net, we will be seeing fewer family crises,” Marlowe says. “The system as a whole is trying to move from a mode of reacting to crisis to a more preventative approach. But not every family’s problems can be solved by Dr. Phil in 60 minutes like on Oprah. Growing into a mature, healthy adult is a process that requires support from family at every turn.”

Too little, too late
But for families already in crisis, it’s too late to build a stronger safety net. In 1998, James and Toni Hoy of Ingleside, Ill., adopted a two-year-old son named Daniel. He displayed developmental delays, had been abused by his biological parents, and had been born under the influence of drugs and alcohol. As Daniel grew older, he began to display violent and aggressive behavior, which became dangerous enough that Toni Hoy says she didn’t feel safe in her own home.

The Hoys tried several methods of therapy and counseling for Daniel, but nothing seemed to work. The final straw was when Daniel, then 13, pulled a knife on one of the Hoys’ other children and threw another child down some stairs.

In 2007, they approached the Department of Human Services (DHS) and the Department of Healthcare and Family Services (HFS) about paying for $180,000-per-year residential treatment the family could not afford. The state declined to pay.

Denied funding for treatment they felt Daniel truly needed, the Hoys chose not to pick him up from the psychiatric hospital. Like the Buschs, they faced a charge of neglect for their psychiatric lockout, and their son became a ward of the state, which eventually placed him in a residential treatment facility.

The Hoys eventually got the neglect charge dropped, but it remained in the State Central Registry of abuse and neglect findings. They sued DHS and HFS to obtain funding for Daniel’s residential care, settling their case in July 2011 with an agreement that the agencies would pay for Daniel’s treatment while not admitting any fault. The Hoys also regained custody of Daniel, who is now 16 and was recently transferred from residential care to a juvenile detention center for assaulting a teacher and damaging a car.

While the Hoy case doesn’t set a precedent for other cases because it was settled before a court ruling, Toni Hoy says she has advised several other families in similar situations, and their case may serve as a catalyst for an upcoming class-action lawsuit.

The Collins Law Firm in Naperville, which represented the Hoys in their case, is examining similar cases to construct a class-action suit that could force changes in how the state handles psychiatric lockouts, custody relinquishment and residential care. Attorney Aaron Rapier at Collins says that suit is still in the planning stages and will not be pursued until later, to avoid jeopardizing the Hoys’ settlement.

In the meantime, John Schornagel at CRSA says the state’s financial woes limit the speed at which agencies can move from reacting to crises toward preventing them.

“State agencies have all been cut back on a variety of services – administration and direct services – and a lot of the nonprofits that do the heavy lifting are in trouble because the state isn’t paying their bills in some instances and they’re cutting back on services they provide to the community,” he says. “It makes being proactive more and more difficult. … I don’t think there’s any bad guys here. The agencies are doing what they can to do a better job with a very, very challenging population. I think they’re beginning to win the war, but there’s always casualties.”

Source article http://www.illinoistimes.com/Springfield/article-8964-when-adoption-goes-wrong.html