Editor's note: To protect the privacy of the boy in the story, his last name is not used. In addition, we have removed the name of his adoptive mother and their hometown.
Numbers defined life in Missouri's foster care system for 15-year-old Mohannad. Nineteen psychologists. Five psychiatrists. Eleven different drugs. Six foster homes. Five hospitalizations.
His seven years in foster care are chronicled in a pile of medical records more than a foot thick. The pages are wrinkled from sitting in a damp garage, the edges stained a dark reddish brown from the rusty paperclips.
Quetiapine, risperidone and oxcarbazepine are just a few of the drugs Mohannad took to control his violent, aggressive outbursts.
He has been diagnosed with attention deficit hyperactivity disorder, mild mental retardation and autism.
Past psychologists and psychiatrists have mentioned other illnesses - oppositional defiant disorder, reactive attachment disorder, post-traumatic stress disorder, unspecified mood disorders and bouts of depression.
Bounced around between foster homes and doctors, Mohannad never had a steady support system. He needed treatment, but the foster care system simply could not keep up with his high needs.
One psychiatrist wrote in an evaluation: "He is probably a rather sad, lonely, confused little boy."
Missouri's foster children
Like Mohannad, more than 30 percent of Missouri's foster children take psychotropic medication, and most of the drugs are approved only for children with severe mental problems.
Often neglected and abused, foster children are one of Missouri's most vulnerable populations. But experts say the state cannot always give children the emotional support they need. Instead, their problems are dealt with another way - by prescribing drugs.
Nationally, 18 percent of foster children are given psychotropic medications. In Missouri, it's nearly twice that amount.
The overprescription of psychoactive medication to foster children is alarming, said Connie Brooks, a psychologist at the Thompson Center for Autism and Neurodevelopmental Disorders.
Even though foster children are at higher risk for behavioral and emotional disorders, Brooks said the sheer number of drugs given to children she sees is cause for concern.
"I can't remember a foster child I saw who was not on at least one psychotropic medication," Brooks said.
At least 20 percent were taking an average of two or more psychiatric drugs, she said, with a few foster children taking up to seven psychiatric drugs.
More than half were prescribed antipsychotic drugs, the class of medication with the highest risks. Antipsychotics are a class of psychiatric drugs used to treat severe mental impairment associated with illnesses like schizophrenia and bipolar disorder.
"Children in foster care often have a number of other emotional problems that percentage-wise would be higher than normal children," said John Hall, a child psychiatrist at the Thompson Center and assistant professor of child and adolescent psychiatry at MU.
Missouri spent more than $81 million on psychiatric drugs for foster children in the last five years. Antipsychotics account for more than half of the state's spending on psychiatric medication for foster children.
In Missouri, prescription records indicate foster children as young as 2 have been given antipsychotics. Hall called that "concerning" and "surprising" because diagnosing and medicating children that young is rare.
What are psychiatric drugs?
Psychiatric drugs, also called psychotropic drugs, are used to treat mental disorders, such as depression, ADHD, bipolar disorder, autism and schizophrenia. Antidepressants, stimulants and antipsychotics are all considered psychotropic medications.
The Food and Drug Administration breaks antipsychotics up into two groups. First-generation antipsychotics, also called "typical" antipsychotics, are the older generation of antipsychotics. Second-generation antipsychotics, or "atypical" antipsychotics, are the newer drugs used to treat mental disorders.
The main differences between the two types of antipsychotics are the side effects and the times at which the drugs were developed. Most notably, patients taking typical antipsychotics can develop a neurological disorder that causes involuntary muscle movement.
Psychotropic medications can cause side effects such as headaches, nausea and dizziness. The FDA states antipsychotics can cause blurred vision, skin rashes and rapid heartbeat.
The FDA adopted a "black box" warning - the most serious type of warning - in 2005 for all antidepressants, claiming the drugs can lead to an increased risk for suicidal thoughts in children and adolescents.
Stimulant medication for ADHD, such as Adderall and Ritalin, most commonly causes a loss of appetite and sleep problems. According to the National Institute of Mental Health, the bipolar medication lithium can cause seizures, irregular heartbeat and blackouts.
The FDA only approves atypical antipsychotics, or second-generation antipsychotics, for children with severe mental illness. The drugs are frequently used to control aggressive behaviors, such as hitting, kicking and biting, Hall said. Other symptoms of severe mental illness can include mood disorders, hyperactivity or hallucinations.
Risperidone, the one antipsychotic approved for children between 5 and 10 years old, is only indicated for aggression associated with autism, Hall said. Risperidone can cause significant weight gain, even in the first six months of treatment, according to the FDA.
Only five atypical antipsychotics are FDA-approved for use in children older than 5. No atypical antipsychotics have been approved for children younger than 5. That's because most medication, not just psychiatric medication, has not been studied in children, Hall said.
"It's harder to meet the research ethics if you're trying to study children," he said.
"Mommy hurt me'
Mohannad was taken into emergency protective custody in 2005 after his mother, who has schizophrenia, had a psychotic episode and tried to bite off Mohannad's fingers, according to hospital records.
He still has scars on his right hand.
A woman in eastern Missouri adopted Mohannad last year. Having a stable home environment has been one of the greatest improvements in his life, she said.
Mohannad's life in foster care was filled with uncertainty, his adoptive mother said. He moved among foster homes five times in seven years because his aggressive behavior prompted families to request removal.
The boy has been suspended from school multiple times for fighting. He bites, kicks and punches other students when he gets angry or upset. One psychologist wrote that as a 9-year-old, Mohannad had a plan to kill his teacher with a big kitchen knife.
Mohannad started taking three psychotropic medications when he was 4. Since then, he has taken six different ADHD medications, two antidepressants, two antipsychotics and mood stabilizers, stopping and starting each one multiple times at varying dosages.
His adoptive mother said medication plays a big part in ensuring Mohannad is capable of functioning at school and at home.
"I don't honestly think he's ever going to be without medication," she said. "Because he really does have a mental illness."
She said she wants the caseworker, psychologists and psychiatrists to all have input when medicating not just Mohannad, but all foster children who come into her care.
"That's one of my goals, to make sure the medication management is a team effort," she said.
Prescribing the medication
One of the most difficult parts of prescribing medication to foster children is inconsistency in medical records and mental health providers, Hall said.
"Quite often, the foster care system doesn't have a really good track record of what they've been given before," Hall said. "So the foster parent who brings me the child knows that these are the two bottles of what he's been taking, but they don't know what else has been tried or how long he's been taking them for."
Getting in to see a child psychiatrist can also be a challenge because children move around so much, Hall said.
"We have a shortage of child psychiatrists across the country," he said. "Sometimes there's a longer waiting list to see a specialist."
The Missouri Department of Social Services acknowledges foster children are often seeing primary care physicians rather than psychiatrists.
Foster families often seek out their primary care physicians because of time constraints. When foster parents are dealing with aggressive and disruptive behaviors, waiting a month to see a specialist is not practical, Hall said.
"They can get in and see a family doctor this week if they've got a problem going on right now," he said.
Most primary care physicians are competent when it comes to prescribing psychiatric medication, Hall said, but they probably do not have the level of expertise necessary for long-term mental health care. They might also be "uncomfortable" managing the medications in the long run.
Another complication is that supervision might be inconsistent. According to Department of Social Services policy, once a foster child is prescribed a psychiatric medication, the caseworker, not the foster parent or doctor, has the final approval for new drugs.
In a "traditional" home, the parent has the primary relationship with a child, Hall said. That is not always true with caseworkers and foster children.
"Sometimes it's not even somebody that knows the child well," Hall said. "The case manager may not have much more knowledge than I do, but they're the one that, from the state's perspective, needs to OK that."
Diagnoses, drugs problematic in children
Hall said he exercises caution when diagnosing young children with a mental disorder, and he uses even more care when prescribing medication.
Until children are up to about 4 years old, it is hard for doctors to distinguish between normal outbursts and what might be a mood disorder or emotional problem, Hall said. Children as young as 8 or 9 can be diagnosed with mood disorders, but anything younger than that is "stretching the boundary," he said.
Hall prescribes ADHD medication for children as young as 4, but even that makes him uncomfortable, he said. Treatment for children that young should be behavioral.
Behavior problems are often the most difficult to handle, and drugs can provide a quick fix, Brooks said. But medications often do not address underlying problems.
"There are all sorts of behavioral interventions or therapeutic interventions that we should try first before we put them on lots of medications," she said. "That's just not how it ends up happening, though."
What children often need is emotional support and therapy, not drugs. One of the most common diagnoses she gives is post-traumatic stress disorder. Children who have experienced abuse or neglect are at high risk for developing PTSD, which can cause aggressive outbursts and violent tantrums.
"Children who are acting out get a lot of consequences when really what they need are some supports that look a little different," she said.
Marlene Howser, a licensed professional counselor at the Burrell Center in Columbia, said there are many therapies that can help treat children who experience attachment disorders and trauma.
Howser said doll houses, painting, puppets and role-playing are all used with young children to help them develop social skills and learn appropriate behaviors. With young children, Howser said sitting down and talking is not effective, so therapists have to be creative in the way they treat the child.
"When trauma occurs, it usually stops a lot of their emotional development," she said. "Often times when there is a lot of trauma, the child may be 15 but have the emotional maturity for a 10-year-old."
Howser said therapeutic board games are also used with younger children to create a fun environment to address emotional and behavioral problems. The board games address everything from anger issues to divorce to self-esteem problems.
Medication sometimes necessary
At one point, Mohannad was on five different psychotropic medications at the same time. Mohannad's medication made him barely able to have a simple conversation, his adoptive mother said.
"He was just looking at me, like he could look right through me. He was just dazed," she said. "You could see the drool coming down."
But she said she is the most concerned about what side effects she can't see.
"I have been really concerned about the long-term effects ... because your organs are being exposed to so many chemicals," she said. "I worry a lot about his liver, about his kidneys."
Mohannad has to have blood tests every three months to make sure the medications are not damaging his organs, she said.
Mohannad now lives in a residential facility during the week, where he goes to regular therapy and learns life skills. He comes home on weekends and his mother said he is "thriving" now.
And despite all of the doctors visits, medication and therapy sessions, she said Mohannad is still a typical kid who loves to laugh and have fun.
"Mohannad has a lot of good days and honestly, he doesn't really have a lot of bad days," she said.
Mohannad's first case manager wrote that he likes hamburgers and video games. He is "creative" and "energetic." He loves his baby sister and likes to play basketball, the caseworker wrote.
"He loves his brothers and his sister. He would never let anybody hurt us, that's for sure," she said. "He loves to laugh. He's so silly.
"Mohannad is just a really sweet boy."
By the numbers
31.1 - Percentage of Missouri foster children on psychoactive medication
18 - Percentage of foster children nationwide on psychoactive medication
5,628 - Number of foster children on psychoactive medication
2,937 - Number of foster children on 2 or more psychoactive drugs
439 - Number of foster children on 4 or more psychoactive medications
2,658 - Number of foster children on ADHD medication
$81,258,125 - Spending on psychoactive drugs for 2010-14
$46,434,560 - Spending on antipsychotics for 2010-14
Source: MoHealthNet, Government Accountability Office