Published Monday, June 18, 2012 | 2 a.m.
Updated Monday, June 18, 2012 | 11:18 a.m.
A turning point
In the early 1990s, Harvard researcher and Massachusetts General Hospital psychiatrist Joseph Biederman advocated for a new take on childhood bipolar disorder, arguing that many more children have the disorder than previously thought. From 1994-2003, due at least in part to Biederman’s work, experts say, there was a 40-fold increase in the diagnosis of pediatric bipolar disorder.
“After Dr. Beiderman, everything changed,” said Dr. Norton Roitman, a Las Vegas psychiatrist who works with several agencies dealing with foster children. “He said that bipolar disorder may not look the same in children and as a result you don’t have to depend on the (accepted criteria) to diagnose it in kids. It was a real breakdown in diagnostic discipline, and it led to the unregulated use of tranquilizers and mood stabilizers.”
In 2008 Congress investigated Biederman for failing to report the majority of his earnings from contracts with pharmaceutical companies, and in 2011 Massachusetts General Hospital and Harvard Medical School disciplined Biederman and two other doctors for conflict-of-interest violations.
Matthew Stewart Pitzer was 9 years old when his mother decided she could no longer care for him.
Pitzer's drug-addicted mother left him at Montevista Hospital, a psychiatric and chemical dependency hospital in the western valley. A few days later, social services called to ask Pitzer's mother to come pick up the child. She refused.
Pitzer, a child who would refuse food because of the consistency, did not particularly like being around lots of other kids and would later be diagnosed with a disorder that inhibits the development of healthy bonds with adults and authority figures, was now a ward of the state. Over the next nine years he was moved 17 times into psychiatric facilities, foster homes and treatment programs of varying lengths, according to interviews with Pitzer, his court-appointed special advocate and his attorney.
Almost immediately he was put on a cocktail of medications to help control his mood.
Pitzer, now 18, chafed at his first placement in 2003, Child Haven in Las Vegas, a facility where he roomed with many other kids and was expected to follow strict guidelines and schedules. He refused to cooperate and within weeks was off to his second placement, Desert Willow Treatment Center, a high-security psychiatric facility.
Pitzer, a rail-thin blond who fidgets with nervous energy, was diagnosed with attention deficit hyperactivity disorder and bipolar disorder after a single visit with a psychiatrist.
He was certainly troubled after losing his only family, but his advocates contend that doling out a drug cocktail to a fourth-grader who had just gone through a significant trauma was questionable at best, reckless at worst.
“I know of all the temper tantrums; I’ve been with Matt longer than anybody,” said Trina Pascucci, Pitzer’s court-appointed special advocate. “That boy has never acted out with me, ever. He didn’t need medications. What he needed was understanding and nurturing that he didn’t get.”
Pitzer’s story is not unique. A study of five states by the federal Government Accountability Office published in December found that foster children were prescribed psychotropic drugs at rates 2.7 to 4.5 times higher than other children on Medicaid in 2008. The study also found foster children were more likely to be on multiple medications. Psychotropic drugs include those used to treat ADHD, anxiety, depression and psychosis. A study published about the same time in the journal Pediatrics found similar results.
In September, the federal Child and Family Services Improvement and Innovation Act, which requires states to come up with protocols for use of psychotropic drugs for foster children, was signed into law. Nevada, where Medicaid was billed $1,348,166 in fiscal 2010-'11 for the psychotropic prescriptions of 765 foster children, last year passed its own set of new laws governing foster care and the use of psychotropic medications, and they are currently being put into practice.
Attention deficit hyperactivity disorder is a chronic condition that affects millions of children and often persists into adulthood. ADHD includes some combination of problems, such as difficulty sustaining attention, hyperactivity and impulsive behavior. Children with ADHD also may struggle with low self-esteem, troubled relationships and poor performance in school.
— Mayo Clinic
It will take time before the new laws can be assessed, but advocates for foster children are watching closely and already pursuing other measures to augment the regulations.
When she went to see Pitzer at the psychiatric facility, Pascucci said the boy was listless and had gained 25 pounds in less than two months.
“He walked out of there looking like bloated Elvis just before he died,” Pascucci said, adding that Pitzer was taking up to five medications at a time, some for the same symptoms. “He was bloated from drugs. His pants didn’t fit, he couldn’t even button them. And Matt is the kind of kid who has never had a chunky phase, he’s always been very thin. He was very sedated. Matt is pretty perky normally, and (keeping him sedated) might have been their intention.”
Pitzer moved from placement to placement, saw at least three different psychiatrists. and his prescriptions changed frequently. By age 11 he was on a mix of drugs that left him unable to get up in the middle of the night to go to the bathroom or focus on school work. He was becoming increasingly disillusioned and detached, but he was still too young to push back.
When needs aren't being met
When Manny Solario first saw Pitzer walk into his special education class at Variety of Southern Nevada, Solario said it was clear Pitzer was a child who needed help.
Pitzer was 12 years old and had already attempted to kill himself twice. Solario said Pitzer looked like a “zombie” because of the medications he was taking.
One day Pitzer came into Solario’s classroom with fresh bruises around his neck, the result of another suicide attempt.
“The kid is 12 years old and he’s already tried to kill himself three times,” said Solario, who gradually became a mentor to Pitzer. “For a 12-year-old to want to take his life is unbelievable. He was normal in school and was a good student, all things considered. So I called his caseworker and became more involved.”
It was a turning point. Finally, someone who wasn’t appointed by the state had taken an interest in Pitzer. He was still on the medications though, which he despised.
“When I was living with my mom I was living in an RV in a mobile home. I lived under a freaking table. That’s where I slept. That was my life,” Pitzer said. “That was how I was raised, but when I got taken away from that it just drove me crazy. I lost everything. I didn’t have my parents. I didn’t know these people I was going into foster care with who were giving me meds and telling me I have to do all kinds of stuff.”
Bipolar disorder and ADHD are not caused by environmental stresses, according to Dr. Norton Roitman, a Las Vegas psychiatrist who works with several agencies dealing with foster children. Roitman also was one of the authors of Nevada’s 2011 legislation.
“The increase in use of psychotropic medications in the last 20 year has been remarkable,” Roitman said. “The problems we are seeing in kids are more likely due to unmet needs rather than an increase in illnesses. The worst part is that a lot of these kids start to really believe something is wrong with them, but they have no understanding of the diagnosis.”
Bipolar disorder — sometimes called manic-depressive disorder — is associated with mood swings that range from the lows of depression to the highs of mania.
— Mayo Clinic
Pressure to keep moving
The vast majority of foster care children are on Medicaid. Reimbursements are low and the paperwork burden is high, psychiatrists say, and many doctors feel pressure from care providers to find a diagnosis and prescribe something. Bipolar disorder is more likely to garner Medicaid reimbursements than other diagnoses, doctors said, and most of the prescriptions are covered as well. More nuanced or less prevalent diagnoses may not be reimbursed by Medicaid, and a prescription is easier to fill than a need for a psychosocial program and personal treatment.
Foster care providers in Nevada, though not paid more for housing children who take psychotropic medications, receive higher levels of funding and assistance depending on the level of care they provide. The more challenging the children’s diagnosed problems, the more foster care providers receive.
“They put kids on meds to control them,” Pitzer said. “I think it’s to make the foster parents' job easier and for financial benefits. I’ve seen kids on five different pills, and they are all drugged out. They’re sitting there watching TV drugged out or in school just drugged out. It’s easy, it’s not a job for the foster parent to do; they are getting paid to sit on their butts and watch us.”
It is not just foster children who see it that way. Children entering the foster system are seen as victims but then shift to becoming a problem that needs to be solved, said Janice Wolf, Pitzer's lawyer and an attorney at the Legal Aid Center of Southern Nevada who heads the Children’s Attorneys Project.
“Foster kids are held to a higher and different standard than biological kids,” Wolf said. “If they get into a fight with a fellow foster kid, there’s a police report. If a kid with his parents fights a sibling, he gets scolded. Turning to medications to treat behavior and not actual illnesses creates a lot of issues for these children. Some of the older ones would like to join the military, police or fire forces, and they can’t do that. You’re kind of doomed if you're on meds, because they won’t accept you.”
Ollie Hernandez, 20, was in and out of foster care in Las Vegas from the time she was 9 years old. Her mother died when she was 11, and Hernandez had been removed from an abusive living situation with her aunt and uncle. Like Pitzer, Hernandez was evaluated quickly, diagnosed with ADHD and anxiety disorder and placed on multiple medications.
“My issues and trauma needed to be talked through,” Hernandez said. “(Medications were) just numbing me and not doing anything to fix the problem. I was tired all of the time. I was drowsy and couldn’t function.”
Over time, Pitzer’s list of diagnoses and medications grew. At different times he took the antipsychotics Abilify, Seroquel and lithium, the antidepressants Strattera and Wellbutrin, the mood stabilizer Depakote and the anticonvulsant Lamictol. Other than ADHD and bipolar disorder, Pitzer also was diagnosed with reactive attachment disorder, oppositional defiant disorder and antisocial personality disorder.
Pitzer got into plenty of trouble. He smoked pot, broke windows and shoplifted. Yet, those close to him at the time said his behaviors were symptoms of his chaotic life and lack of stability, not of a deeper mental disorder.
By 2010, Pitzer was fed up with his medications and at 16 years old felt mature enough to stand up for his rights.
He was in a foster home with other children when he went to see a new doctor.
“The psychiatrist had never met with Matt before,” said Wolf, who went to the meeting with Pitzer.
Reactive attachment disorder
Reactive attachment disorder is a rare but serious condition in which infants and young children don't establish healthy bonds with parents or caregivers.
— Mayo Clinic
With barely a cursory review of his records and within 15 minutes of meeting Pitzer, according to Wolf, the doctor declared Pitzer had bipolar disorder and began to prescribe a new series of medications. Pitzer and Wolf refused, knowing that Pitzer had already quit taking his old medications and was feeling much better without them.
“He gave Matt this lecture about if he got in trouble it would look bad if he wasn’t on medications because he had a history of anger issues,” Wolf said. “He really did quite a number on Matt to try and get him on the medication.”
Pitzer stood his ground, and after seven years, was finally off the pills. Even better, Solario, whom Pitzer was calling “dad,” was working to fulfill the necessary requirements to adopt him.
Pitzer was staying at a group home in North Las Vegas in November 2010. It was days before his 17th birthday, and if all went as planned, Solario would finish the adoption process by the weekend.
Then the system blindsided Pitzer one more time, sending him over the edge.
Oppositional defiant disorder
Marked by a persistent pattern of tantrums, arguing, and angry or disruptive behavior.
— Mayo Clinic
Nevada takes steps forward
For the 2010-2011 fiscal year Nevada had 7,224 children under state care, with 5,311 of those in Clark County. That figure covers all children who were under some state supervision and includes those who may have been removed from their parents and later returned, or those who were never removed but still had supervision. As of May 2012, according to Child and Family Services Deputy Administrator Jill Marano, there were 4,140 children in out-of-home placements in the state.
Medicaid covers nearly all foster children. Medicaid records show that from fiscal year 2008 to fiscal year 2011 the number of foster children receiving psychotropic medications increased from 616 to 765, and the amount billed to Medicaid nearly doubled from $675,134 to $1,348,166. During that time, the number of foster care children in Nevada actually declined slightly.
In 2011 the Nevada Legislature passed a series of laws designed to better regulate the administration of psychotropic medications to foster children.
One of the primary provisions of the new law is that every child in foster care who needs psychiatric care or who is taking psychotropic medications must be assigned a “person legally responsible for the psychiatric care of the child,” who is approved by the court.
The caregiver is responsible for decisions regarding the child’s psychiatric care.
The law also created greater restrictions on the use of psychotropic medications with children, and new reporting requirements.
One of the major problems prior to the new law was that Medicaid and child welfare databases were disconnected. There was no reliable data on how many children in foster care were on psychotropic medications and how many different pills they were receiving.
“Nevada is not unique in this issue of psychotropic medications and tracking what meds kids are on,” said Marano. “One thing we noticed when we attended seminars and training was that we are one of the few states that have addressed this in law. I’m excited as we move through the process. We could actually become national leaders and ensure kids are getting good medical attention. I’m hopeful.”
The mandate was unfunded, however, and the Department of Child and Family Services had to move resources around to start the program.
“I think it was an even-handed approach,” said Roitman, acknowledging his bias as an author of the legislation. “Instead of regulating doctors or pharmaceuticals, we wanted to bring it to a personal level and have someone act in the role as parent for every foster kid. So, you just want someone who knows the kid well, and that’s the part that gets missed a lot. You need to know about the kid, the drugs he was exposed to, his medical history, allergies, and what has been tried and failed.”
Antisocial personality disorder
Antisocial personality disorder is a type of chronic mental illness in which a person's ways of thinking, perceiving situations and relating to others are abnormal and destructive. People with antisocial personality disorder typically have no regard for right and wrong.
— Mayo Clinic
Too soon to gauge success
Under the new law the first choice for the person legally responsible is a parent or family member. If a suitable relative, or someone else close to the child, cannot be found, the duty will fall to Child and Family Services staff.
Until it is determined how many foster children are on psychotropic medications and if they have a relative eligible to oversee their medical care, it is impossible to know what the caseload for the agency staff will be.
For example, Kevin Schiller, director of Washoe County Department of Child and Family Services, told the Legislative Committee on Health Care in May that the department had 171 children on psychotropic medicines and had assigned two social workers to work on their cases. It remains to be seen how many parents or relatives they will find to be the parties legally responsible for psychiatric care.
“That’s the piece that, as we get deeper into this, we’ll have to see what that workload will look like, and as we set this up if the plan is achievable,” Jill Marano said.
There are also reports of doctors balking at the added paperwork the program calls for, as foster parents are now required to get a written explanation from the doctor for all prescriptions a child receives.
“Physicians get so frustrated with uncompensated time, and Medicaid payments are low to start,” said Erica Ryst, a psychiatrist at UNR and consultant to Washoe County. “They decide not to treat this population of kids because it becomes too burdensome, but these are some of the most needy children there are. So in some ways new requirements can kind of have the opposite effect.”
Wolf is still consulting with Clark County and Nevada Child and Family Services, as the Legal Aid Center represents all foster children in Clark County who receive psychiatric care.
Wolf has called for better recordkeeping, including a “medical passport” that would stay with each child, better review of current treatments and higher commitment to mental health, such as community-based mental health services.
“The jury is still out on whether or not the ‘person legally responsible for treatment’ system will work,” Wolf said. “It still remains to be seen whether the nonparent surrogates will be up to the task of attending all of the psychiatric and treatment meetings and get informed consent.”
The GAO recommended in its report that the U.S. Department of Health and Human Services create nationwide guidelines.
“In terms of addressing the issue legislatively, my impression is that our state has really jumped on the bandwagon and has started to tackle these issues in a concrete and practical way,” Ryst said. “A lot of states aren’t doing that yet. But months or two years from now, the feds may come up with specific guidelines that trump what the states are doing.”
Moving beyond the past
A few days before his 17th birthday, Pitzer’s caseworker – for reasons still unexplained and unclear to all but the caseworker – picked Pitzer up from a group home in the middle of the night and placed him in the White Pine Boys Ranch, a treatment facility in Lund. It was days before Solario was scheduled to take custody of Pitzer.
The move was illegal, as the caseworker was required to inform Wolf and Pascucci of any new placement.
The caseworker was unavailable for comment.
Pitzer was furious that he was being moved again, and he snapped. He could not get in touch with Pascucci or Solario.
Pitzer was brought back to Las Vegas to Child Haven, the first group home where his state-operated ordeal started 8 years earlier. He ran away and spent the next year on his own.
After he turned 18, he contacted Wolf, who worked out a deal with the courts: Pitzer would work toward his high school diploma or GED and find a job. He is given a stipend to live on his own and still receives some state supervision. He has not had any run-ins with the law since the day he ran away.
Pitzer sees Solario weekly and Pascucci and Wolf regularly. He's training to be a mechanic because he wants to be a “grease monkey."
“I take responsibility for my actions 100 percent,” Pitzer said. “No one can make me smoke weed. No one can make me do delinquent activities. No, I did that. I chose that. It’s my responsibility to have to live with it. But give us foster kids resources, give us something to do with our lives and help us mature and grow. You know, like a family would.”
“Frankly, I knew him when he was 9 years old and he became more angry in the system,” Pascucci said. “The system doesn’t work. The kids are like chess pieces being moved around, and it’s not for their benefit. When they are small they don’t really understand, but as they get older and start to understand the system they’re in, they get frustrated and angry. They want to put down roots. They want a family and permanency. Myself and our team failed this boy. It’s not because we could have done things differently necessarily. We didn’t do right by Matt, and we know that because he stayed out of trouble when he got out of system, when he ran away. We failed him because we never found him permanency.”