Janey is 5. She hits and she bites. Her third foster mother, Sandy, is thinking it’s too much to handle. I am her new psychopharmacologist. Janey arrives with a thick chart documenting in utero substance exposure, early neglect, many placements, and symptoms consistent with many DSM-5 diagnoses, including reactive attachment disorder, generalized anxiety disorder, disruptive mood dysregulation disorder, attention deficit hyperactivity disorder, and post-traumatic stress disorder.
Her symptoms include poor sleep, impulsivity, over-activity, irritability, easy startle, and sudden bursts of aggression. Her social and academic function are severely hampered. She is being treated with a combination of methylphenidate extended release 18 mg and risperidone 2 mg each morning; mixed amphetamine salts 5 mg in the afternoon; and quetiapine 25 mg at night. Once Sandy coaxes Janey inside, my new patient huddles near the door, with no intention of interacting.
And I’m supposed to evaluate Janey’s medication regimen over the next 45 minutes. Sound familiar? This is a typical patient in the schedule of a child psychiatrist who does work with foster families. The psychopathology is often extensive, and there are many social and economic factors impeding treatment.
Add to this the fact that, in response to the rising use of psychotropic medications in Medicaid and foster care populations, some states, including California, have implemented specific guidelines with requirements such as:
A minimum amount of time with the child
Collateral information from caregivers, teachers, therapists, and others
Medical screening and follow-up
Clear documentation of diagnoses and target symptoms
Documentation of rationale for all medication decisions
Emphasis on nonpharmacologic treatment and intervention
The reality, of course, is that kids like Janey and doctors like me are often left with less time and fewer resources than are needed. So, while medication never makes up for an inadequate plan, sometimes we are stuck with an inadequate plan.
The only way to successfully do these evaluations in a timely fashion is to break the process down into a series of manageable steps.
1. Establish rapport. My first job is to spend at least five minutes listening to the struggles being experienced by the caregiver. Sandy says she has two other foster children and gained custody of Janey 3 months ago. She’s clearly overwhelmed.
When you encounter a foster parent under this kind of pressure, it’s important to take stock of the array of community supports that are available and to ensure that the parent is taking advantage of them. Our clinic has a checklist of such supports, and we give them to parents on intake. They include psychotherapy (both for the child and the parent), foster parent training, and others (see the accompanying article by Dr. Stewart on psychosocial interventions for more options).
2. Record the patient’s symptoms, with an emphasis on (1) those that are most problematic for behavioral management, and (2) those that have been present over the past several weeks. Foster kids often present with a long trail of documented psychiatric problems over the years. While it would be nice to review and digest all this information, you’d only have time for one patient per day if you did so. Instead, focus your attention and questions on the past few weeks.
In addition, acknowledge that not all symptoms are created equal. In a situation where the behavior is so problematic that the placement is in jeopardy, you need to focus on what you can to solve the acute problem. In this case, it is the hitting and biting that are creating the crisis.
3. Break down the behaviors in terms of discrete target symptoms that might be most amenable to medications. At this point, you’re not yet deciding on which meds to prescribe; you are simply thinking broadly about the possibilities. For Janey, I ascertain that she is often reacting to a very busy environment, and that the people working with her have been more focused on reducing the problematic behaviors rather than understanding them. Furthermore, she does have some moments of calm, connected play, and learning—a strength that I want to encourage.
4. Evaluate the list of medication options by balancing the potential benefits with the potential toxicity. In general, we are most concerned about the side effects of antipsychotics. The major issues vary depending on the medication, and can include weight gain, dystonia, sedation, cognitive slowing, and akathisia, as well as a lowered seizure threshold. As I look at Janey’s regimen, I’m concerned that she is on two different antipsychotics. While I will learn more about the rationale for the combination when I review old medical records, I suspect that the quetiapine was added for insomnia, which in turn was likely aggravated by the afternoon dose of mixed amphetamine salts. While risperidone may be reducing Janey’s irritability, I wonder if it is causing akathisia, which in turn could induce apparent over-activity and anxiety (Burcu M et al, Journal of Child and Adolescent Psychopharmacology 2014;24(3):112–119).
5. Document your informed consent process. While some clinicians view informed consent as a pro forma exercise at the very end of an evaluation, when dealing with the foster care system, you are dealing with a highly scrutinized clinical environment. I think about informed consent as a process that happens throughout the evaluation as well as an ongoing conversation throughout treatment. For example, as I ask Sandy about Janey’s symptoms, I educate her about risks and benefits of the common meds, and make sure she knows that there are non-medication options available. (A good list of questions to evaluate the need for medications can be found in this blog post in Psychiatric Times.)
6. After your evaluation, spend a few minutes creating a plan to obtain more information. After your patient leaves, and before you see the next patient (who is probably already in the waiting room), create your plan for gaining more information.
I schedule more time with Janey to try to establish some connection with her. I ask my front office staff to obtain other medical records and school records, and I send off an email to the therapist to find time for a quick chat at some point over the next couple of weeks. It turns out that there is a teacher at school who has a very positive and effective relationship with Janey, and we are able get a message to her to ask her to share with us more about that.
In addition, since we do not have time to complete our usual medical workup, I make a note to have my staff schedule the patient to come in a half hour earlier for her next appointment to get fasting labs and an EKG.
In this introductory meeting, the best I can do is to begin the assessment and treatment process. I review the diagnoses, the target symptoms, the current medication plan, including the risks of the medications, and whether neuroleptics are being used for FDA-approved indications. I try to talk about other options, including no medication, while listening to Sandy’s fear that without more medication she will have to have Janey removed.
We are often faced with what appear to be insolvable problems, but in fact this is rarely the case. The key is our willingness to persevere, to re-review everything, look again for things we can change, and to persist in our efforts to develop rapport with children like Janey. We also have to devote the time needed to make calls to teachers and therapists, and to develop relationships with caregivers. Once Sandy is feeling heard, will she be more able to commit her energies to Janey and then rework the sleep hygiene plan and perhaps move away from quetiapine? When Janey figures out that I am unflappable and happy to see her, will she begin to settle down in my office and allow me to interact with her, play, talk a bit, and even get her height and weight? With regular calls to the teacher, will the school rethink its behavior plan, the one that is focused on compliance, and consider a revision that emphasizes empathic support?
We hear back from the teacher. We are able to have her summarize in three simple bullet points what works for her to share this with the entire team. These include: 1. Empathy first: She always responds to Janey’s difficult moments as if Janey is in distress, not being mean; 2. Give her more time to respond: Patience and calmly waiting makes a big difference, allowing Janey to think and respond to requests; 3. “We” attitude—instead of speaking to Janey in terms of “You need to…,” the teacher would frames her suggestions as a shared process with Janey. These three chief tips reduce the frequency and severity of Janey’s difficulties substantially, obviating the need for some of her medications.
Six months later, Janey is happy to see me at our triweekly visit (the best I could arrange). We have gotten labs and an EKG, and replaced the quetiapine with a very small dose of diphenhydramine. Her body mass index has stabilized—a partial victory in the effort to reduce neuroleptic exposure. Janey still hits and bites, but a little less as Sandy is more able to hold steady at home; we have found more community supports for Sandy too. At school, Janey has become close with the media center aide, where she spends too much time, but at least she is not in as much open conflict with her peers. In light of these improvements, Sandy has agreed to try to decrease the risperidone to 1.5 mg on school days. Janey’s therapist has been using an evidence-based trauma-informed approach all along. Her confidence in her work was thin when we began, but now she knows that I believe her approach is a good one and she is able to persist, with gradual progress for Janey in her ability to talk and play and draw about her life. We are moving in the right direction.
There is nothing easy about treating children in foster care. The problems are complicated and tough to treat, and there are no guarantees. The kids like Janey who I see sometimes respond, and sometimes they do not. Placements can change suddenly. In fact, by the time we are consulted, sometimes it is already too late: We might be doing an assessment with a caregiver that has given up. And sometimes we get things stabilized, then reunification processes begin, with the hope that a biological parent or family member will now take over. The challenges never end. My experience over many decades is that, with steady persistence, we usually make progress, enough to maintain hope.