A recent investigation by The Imprint, Medicated in Foster Care: Who’s Looking Out?, revealed that states have failed to adequately monitor the use of psychiatric medication on foster youth. Dozens of young people with histories of trauma described how their pain and anguish was muffled but not healed by a broad category of drugs known as psychotropics, many of which cause long-lasting and harmful side effects.
One scholar took a unique approach to scrutinizing this public health issue. Between 2017 and 2019, she went inside settings where decisions to medicate foster youth are made: an Illinois residential treatment facility, and an office where a team of nurses and psychiatrists deliver second opinions on prescriptions for antipsychotics, antidepressants, anti-anxiety meds and stimulants. Staff at this unique medication audit program have the legal authority to approve or deny every psychotropic drug prescribed to foster youth across Illinois.
Katie Gibson — a postdoctoral fellow at the University of Chicago’s Crown School of Social Work — summed up her research in her 211-page dissertation, which was later published in excerpted form by the peer-reviewed journal Social Service Review. To learn how the drugs were “framed in policy and regulated in practice,” Gibson conducted an ethnographic study, sitting side-by-side with prescribers and reviewers.
Gibson was never prescribed psychotropic drugs during her childhood, although her research was partly motivated by her personal experiences as a former foster child and adoptee.
In her dissertation research, she came away impressed by the professionals she observed, and grateful for their transparency. But she also began to question the medication “audit” oversight model. Gibson argues that while audit programs like the one she observed can contribute to improving some prescribing practices, they also deepen the foster care system’s reliance on stigmatizing mental health diagnoses that center children as the problem — instead of the troubled institutions that house them.
In an interview, Gibson described what drove her to conduct this singular and exhaustive study, and her takeaways as both a scholar and a “former foster kid” herself.
This conversation has been lightly edited for space and clarity.
What inspired you to conduct this inquiry?
In earlier research, one interview struck me, where a caseworker said something about how medications were making the whole system work.
I was like, “Oh, wow, if that’s true, that’s really interesting.” I knew oversight programs had been created, and that there was still a problem of high rates of use. But I wanted to suspend my sense of what kind of problem it was and just look at: maybe there are also solutions in some settings.
It also struck me that this system takes kids away from their parents, and like 40% of removal cases have involved parents using drugs of some kind. And they get treated punitively. Yet the foster care system itself has been accused of abusing drugs in a different way. What is going on culturally in the broader American foster care system that that’s what’s happening?
You’ve also suggested you were inspired to devote so many years to this project based on your experience growing up in foster care. What did you observe about how the system works or doesn’t work?
Part of my experience was me being taken and put into foster care at a very young age and being adopted. And being kind of mistreated and used along the way. My adoptive parent kicked me out when I was 17. So then I was living with different families for a couple of years outside of the system.
This person who adopted me — after adopting me, a few years after — lost her license to be a foster parent. My brother had an even worse experience.
Just seeing how that’s not at all unique, unfortunately, that it’s systemic — that kids are taken away from their parents, then abused in the system, then left to be homeless or imprisoned as adults. The child welfare systems predictably produce those outcomes. I guess part of what I wanted to understand is, how does that work? How do we predictively produce those outcomes?
Looking at meds gave me a sense of how medications and diagnoses help to construct children as the problem instead of institutions and other cultural issues.
Was it difficult to persuade these professionals to let you do this, to observe their work so closely in these settings where they are handling the most sensitive mental health information about vulnerable kids and families?
Not at all. People were very generous with their time, and they were very interested in the problem and wanted to know the complexity of it.
And I found a lot of people who didn’t want to be misrepresented, obviously, because especially in Illinois, media coverage of the system has not been very kind or nuanced sometimes. I had people reminding me of that pretty frequently.
I got a sense that people are very excited about research being integrated into the system and trying to use that to reflect on practices, and improve them.
“It feels like we’re moving into a paradigm of foster care where it’s just assumed that children in foster care are severely mentally ill, or many of them will become that at some point in the system. That’s a really dangerous and skewed way of seeing youth in foster care, because it legitimizes all kinds of other abuses.”
You note there is evidence these offices have helped reduce the use of multiple drugs on kids and you say they are efficient about flagging kids who are experiencing bad side effects. But you also note they do not explicitly aim to reduce medication use. In their focus on educating prescribers, you argue, they often end up not questioning prescribers practices or diagnoses strongly enough.
Is that a fair way to summarize?
Not even the right diagnosis — just the assumption that there always is a diagnosis. I didn’t listen to any phone calls where there was a question about whether or not the child had a diagnosis, which was just remarkable to me.
It’s a five-minute phone call based on a two-page form — you have nurses or whoever’s working with the kid very briefly writing down symptoms, often just “aggression,” or something like throwing a deck of cards at the wall. And that’s considered a symptom.
It’s the automatic coding of all children’s behavior in the foster care system as pathological, as signs of their own internal disorder rather than what people also recognized every single day: this could very well be a problem caused by an adult in that space, or a sign that a relationship has gone wrong in that setting, that has very little to do with the kid being sick.
What the research taught me was that the numbers don’t tell enough of the story: It feels like we’re moving into a paradigm of foster care where it’s just assumed that children in foster care are severely mentally ill, or many of them will become that at some point in the system. That’s a really dangerous and skewed way of seeing youth in foster care, because it legitimizes all kinds of other abuses.
Another issue your studies point out is something that came up in our reporting: Many people say foster youth have high rates of mental illness, so it makes sense that they would have higher rates of psychotropic drug prescriptions.
But some child welfare experts think the numbers are still too inflated, that there’s no reason to think foster youth should have such vastly higher rates of ADHD, for example, because its symptoms are so similar to trauma reactions that cannot be treated with psych meds. Did you see that play out?
Prescribers talked a lot about just this frustration of not knowing what they were treating and feeling like they were treating trauma.
Everyday common sense amongst the prescribers and nurses was like, “We’re not treating any of these disorders that we’re writing down. This kid doesn’t have that disorder. This is a kid that has trauma.”
“All these drugs, when you first hear it, you think, ‘I can’t believe a child is being medicated with that.’ We know it’s intense for an adult, and there’s little research on its long-term effects for kids.”
At the residential facility where you spent 14 months, how did you hear the line staff caring for the children discussing medications?
I expected a lot of people to be talking about it every day, and debating medication. And then I got into these sites and very few professionals are talking about this unless I asked them.
Even just thinking about consent — how do you teach a child about consent and bodily autonomy when you’re forcing them to put things into their bodies that they don’t want to have put in their bodies every single day? That was not a question anyone was asking.
And it seemed glaringly obvious to me. They’re worried about teaching teenagers sexual consent, but not about medical consent.
That’s my sense once you get people talking about it: They’re like, this is not what we should be doing, but it’s better than the alternative — which is having the kid run away. But that tells you a lot about those placements too.
This might violate your approach as a neutral observer for this study, but were you ever tempted to speak up on behalf of any children whose prescriptions you saw being approved that sounded risky to you? You mentioned a boy named David who ended up hospitalized because of his medications, for example.
You also explain there’s an intimidation factor for underpaid, overworked caseworkers dealing with more-credentialed psychiatrists in these settings. But were there moments where you wanted to say “hold on”?
The first day, first week at the prescription oversight office, I thought, “Wow, that’s crazy,” what I was hearing. You know, antipsychotics like Thorazine, Seroquel. All these drugs, when you first hear it, you think, “I can’t believe a child is being medicated with that.” We know it’s intense for an adult, and there’s little research on its long-term effects for kids.
But that is something to note about what it’s like to work in the system: Everyone experiences this kind of normalization process. You come in and you’re alarmed, and then over time you start comparing it to the worst — to the worst case you see, rather than to the norm outside of the system, which is very different.
We’re going to have even more of a public health crisis given all of the side effects that I saw kids having.
Maybe if we’re lucky like these kids won’t grow up and have long-term negative effects, but a lot of them are already experiencing them. Boys are lactating and growing breasts and all kinds of things. Even if there isn’t a long-term effect, it can be psychologically confusing for the child and embarrassing.
I wonder if I should have spoken up a little bit more sometimes. I was asked what I thought sometimes and shared then. But my role was to observe and speak about it afterwards.
So, if not audits, or audits alone, then what? Are consent policies a key missing piece that you see?
Informed consent, for sure. The thing is, that’s hard to enforce.
We need to maybe bring in other forms of expertise, particularly the expertise of people who are much more mobile than doctors — social workers and teachers and even nurses. Nurses are really central to the work that I saw in terms of the knowledge that they bring to making decisions about medications. They relay information from all these different people to the doctor, who is very immobile, generally, and absent often.
