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Nina_Stern_McCullaugh

It’s been about six years since child welfare authorities were tipped off to trouble in the home of then-seven-year-old James, near Downtown Los Angeles.

James’ mother had become chronically ill and delegated his care to his older brother, who was also a minor. The brother repeatedly physically abused him, and eventually James was removed from the family’s home and placed in foster care.

As one would expect, James was upset about all of this. Already traumatized by his chaotic home life, he began acting out angrily. Eventually, he was hospitalized for a two-week psychiatric evaluation.

In the hospital, James was diagnosed with bipolar disorder, despite the fact that bipolar is a condition most psychiatrists believe cannot be accurately diagnosed in preadolescent children. And based on that diagnosis, he was prescribed a powerful psychotropic medication, even though that medication had never been approved for preadolescents.

It was a stunning pair of missteps but only the beginning of James’ ordeal. After his release, he was placed in a therapeutic group home, where staff psychiatrists—working under contract for the state’s Department of Mental Health—repeatedly affirmed his diagnosis of bipolar disorder and wrote new prescriptions for psychotropic drugs.

With his behavioral problems escalating, James, then 8, was assigned a Court Appointed Special Advocate (CASA), Nina Stern McCullaugh.

Right away, she saw that his anger problem was only being made worse by his treatment plan.

“Bipolar has become a convenient diagnosis within the foster care system,” Nina says. “The diagnosis of a biologically based psychiatric disorder allows psychiatrists to prescribe psychotropic medications to children. And in a system that is severely lacking in therapeutic resources, medicating kids is often seen as the only way to deal with their behavioral problems.”

But it’s not the way to heal them. On three separate occasions over the next three years, Nina got the court’s approval for James to be evaluated by independent or non-group home mental health professionals, and each time he was found to have not bipolar disorder but, primarily, post-traumatic stress disorder (PTSD). PTSD is the prevailing diagnosis for kids in foster care, and it is treated more effectively with intensive psychotherapy— which the independent experts strongly recommended for James—than with medications.

The problem with a PTSD diagnosis is that the number of qualified therapists available to kids in foster care is grossly inadequate. Most of the therapists who have worked with James, for example, have been either interns working on collecting hours to get licensed or clinicians with limited experience in trauma-focused care.

“They have good intentions, but they aren’t very experienced with kids who have James’ degree of trauma,” Nina says. “On top of this, several of the therapists he has made a connection with have moved on after less than six months. Consistency of care—gaining trust in one’s clinician—is a prerequisite for a positive therapeutic outcome, but it’s rarely there for our kids.”

So year after year, with James making little progress in therapy, group home doctors ordered up varying combinations of psychotropic drugs to try to quell his aggressive behavior, including antipsychotics, mood stabilizers, antidepressants, and even medications originally approved to treat high blood pressure and schizophrenia—all before he reached the age of 12.

Far from improving, James’ mental health continued to worsen and his outbursts became more violent. One year, he was suspended from school more than 15 times.

His physical health deteriorated too. He lost 20 pounds in four months while taking one stimulant. He then gained 60 pounds in a little over a year after being prescribed—despite his family’s history of diabetes and hypertension—an anti-psychotic medication known to cause metabolic disorders.

Alas, James’ experience isn’t unique among children in foster care. In fact, it isn’t even unusual. There are thousands of children in the same situation—misdiagnosed, overmedicated, and failed by the very system set up to protect them—throughout California.

A massive investigation by the Bay Area News Group, published in the San Jose Mercury News in August 2014, has helped bring the issue statewide attention. And in April, a high-level group of stakeholders developed a new set of guidelines for doctors prescribing psychotropics to kids in foster care, stating, “Psychotropic medications should not be used for the purpose of discipline or chemical restraint, except as acutely necessary in true psychiatric emergencies.”

The directive is nonbinding, but work is also being done at the local level.

Last year, Nina was invited to represent CASA of Los Angeles on the court’s Psychotropic Medication Committee, a group that has been working for several years to improve prescribing practices in L.A. County’s foster care system.

She continues advocating directly for James too. She has held his educational rights for four years and has succeeded in getting him a number of school-based education services to address his special needs.

And her fight to have him taken off potentially harmful psychotropics recently took a dramatic turn. In December, after thoroughly documenting his physical and mental health problems, she persuaded the court to order James off the medication that had caused his weight gain. He is now down to a single medication, one with fewer side effects than the others he had been taking.

Once James got off the drug that had caused his weight gain, he excitedly enrolled in a personal training program and quickly lost ten pounds. But the effects of years of trauma and pharmacological tinkering will take a long time to undo. He is still often withdrawn, even from Nina—tending to reach out to her only when he’s in great pain—and he has been struggling in school.

He has a new therapist, however, who is much more involved than previous therapists, and Nina is hopeful there will be continuity in their relationship.

“We probably couldn’t have prevented what happened to James in his family’s home, but we certainly could have done better by him once he went into foster care,” Nina says. “He had been an A-and-B student. He was artistic and athletic and showed a lot of love for people and animals. As he enters his teen years, I hope from the bottom of my heart that he regains his sense of self-worth and motivation to excel.”