When I was a young boy, my parents decided to share their love by fostering children. Two children stayed with us briefly. Then, a 4-year-old girl was sent to us who had experienced numerous forms of abuse. After a year, we adopted her while another family in town adopted her siblings. The adjustment did not come easy, but my parents were certain that with love and discipline, we would be a healthy family.
Unfortunately, my parents were wrong. They weren’t prepared to take in a new family member, especially one who was hurt, angry and scared. A social worker offered friendly advice about potential financial resources, but that was about it. We needed professional therapy to help my sister overcome her traumas and help us heal and grow as a family. I did what I could to protect my sister, but at age 12, she was sent to a psychiatric hospital due to severe emotional distress. Her next few years were filled with suicide attempts, hospitalizations, stays at group homes and attempts to reunite with my parents. After many painful years and broken relationships, she moved as far away from her past as possible. She has spent much of her adult life learning to be happy with herself, to be at peace with past mistakes and to not let her past define her.
Decades later and states away, we still have a foster care system that struggles to effectively care for our kids. Placements are changed frequently, eliminating the possibility of trusting relationships, or they’re poorly supported, allowing problems to fester and grow into chaos and crisis. Then, kids go to group homes that are understaffed and unsupported. Foster kids never settle in one place or school or with the same therapist. Many in their teens attempt suicide or engage in other dangerous behaviors that cause them to be either hospitalized or incarcerated. By the time they grow up, they have very little experience with stability, family or trust.
We psychiatrists do what we can during these crises to provide stability and avoid injury, suicide and hospitalization. Those of us who work with foster youth have tried to do the best we can within the broken system. However, now I’m wondering if we’ve made a mistake in trying to work within the system at all.
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Recently, it has been proposed that we’re relying too much on antipsychotic medications to treat frustration tolerance, as well as more severe symptoms such as hallucinations and bipolar disorder. While electronic health records are becoming more commonplace, doctors still do not have access to all the information needed to safely and effectively prescribe medication.
However, a Treatment Authorization Request system in which all families who use Medi-Cal must have their prescriptions reviewed by the state doesn’t address problems within the foster system since it is redundant to the court-authorization process. Instead, it causes delays and interruptions in treatment for kids and families who aren’t in foster care.
The “cheap fix” of limiting prescriptions merely limits options for all kids who have Medi-Cal. If we’re going to reduce prescribing, let’s do it the right way by giving kids and their families the support they need so they don’t reach the point of needing prescriptions in the first place. At the same time, when they need a prescription, let’s provide better support and communication, not further restrictions.
Robert P. Holloway is president of the California Academy of Child and Adolescent Psychiatry and assistant professor of clinical psychiatry and behavioral sciences at USC Keck School of Medicine.