Children and the overuse of strong psychiatric drugs: It’s an issue that continues to make headlines as the newest class of antipsychotics like Serequel, Abilify and Zyprexa become first-line treatment for an ever-growing population of troubled kids. Although these drugs are only approved to treat schizophrenia and serious bipolar disorders, their use has skyrocketed in the last decade or so—sales topped $14 billion last year—and the media has reported widely on the epidemic of children receiving these and other psychotropic medication for attention disorders, depression, anxiety and even post-traumatic stress disorder (PTSD).
The latest controversy over the so-called “atypicals” involves their use among some of the country’s most vulnerable kids—those housed in state or county juvenile correction facilities, as well as in for-profit, privately-run centers. According to a recent investigation by the Palm Beach Post, for example, in just 25 juvenile jails and 3 programs run by Florida’s Department of Juvenile Justice (a fraction of the state’s 116 residential programs, most run by private companies) the DJJ bought more than twice as much Seroquel as ibuprofen in 2007.
“Overall, in 24 months, the department bought 326,081 tablets of Seroquel, Abilify, Risperdal and other antipsychotic drugs for use in state-operated jails and homes for children,” according to the Post article. “That's enough to hand out 446 pills a day, seven days a week, for two years in a row, to kids in jails and programs that can hold no more than 2,300 boys and girls on a given day.”
What’s worse is that the majority of these drugs are being used “off-label” for unapproved (and often inappropriate) uses such as “sleeplessness.” And their side-effects—including sedation, weight gain, early onset of diabetes—as well as possible long-term effects on brain development, make their overuse especially troubling.
A year ago, the trade publication Youth Today published findings from a survey that was sent to each state’s juvenile justice agency asking officials to provide prescribing information for the atypicals Abilify, Geodon, Risperdal, Seroquel, and Zyprexa in state juvenile facilities and to provide the diagnosis listed for each prescription. In total, Youth Today received complete information including diagnoses and drug information from only 5 states (16 states sent incomplete records while the rest never responded), yet these records indicated that some 70% of the drugs prescribed for kids were being used “off-label.”
In Texas, for example, “nearly 4,000 atypical prescriptions were written in 2008, for a total juvenile population in state facilities of between 1,600 and 1,900, with only 29 percent diagnosed with schizophrenia or bipolar disorder and no diagnosis listed for nearly 25 percent of the prescriptions,” according to the Youth Today findings.
“Because Seroquel accounted for so many prescriptions with no diagnosis, Texas officials feared that it had become the ‘sleeping pill of choice’ for agency clinicians…”
Critics of the widespread use of atypicals go a step further, charging that juvenile facilities, under-funded, under-staffed and reduced to warehousing troubled kids, are using these drugs as “chemical restraints;” more effective and less directly abusive than isolation or physical restraints yet cheaper than the use of intensive therapy or other behavioral and community approaches for dealing with disruptive behavior. Antoinette Appel, a Tamarac, Florida neuropsychologist, told the Post that “she was suspicious of the amounts of drugs used by DJJ. ‘They're not allowed to put kids in restraints, so they put kids in restraints this way,’ Appel said.”
The Palm Beach Post’s investigation was limited by the vexing fact that the majority of juvenile detention centers in Florida (like many throughout the country) don’t keep accessible prescription records for inmate mental health diagnoses. Amazingly, “Some companies that operate homes for children don't have drug reporting requirements written into their state contracts,” writes Post reporter Michael Laforgia. But he adds, “Interviews suggest that these homes, too, hand out plenty of drugs. One representative of a private company estimated that a third of the kids in the company's residential programs are taking antipsychotics and other psychiatric medications.”
Of course, the overuse of atypical antipsychotics in kids isn’t confined to correctional facilities. Children covered by Medicaid are disproportionately prescribed these medications. And at a recent presentation to the American Psychiatric Association, Dr. John Goethe, director of the Burlingame Center for Psychiatric Research in Connecticut, reported that over the last 10 years, “more than half of all children aged 5 to 12 in psychiatric hospitals were prescribed antipsychotics.” Some “95% of these prescriptions were for second-generation antipsychotics,” according to Maia Szalavitz writing on Time’s Healthland blog.
“Many of these children didn't have a condition for which the drugs have been shown to be helpful: 44% of youngsters with post-traumatic stress disorder (PTSD) and 45% of children with attention deficit hyperactivity disorder (ADHD) were treated with them,” adds Szalavitz.
Make no mistake; mental health problems are rampant among children sentenced to juvenile correction centers. According to the group The Future of Children, a collaboration between Princeton University and the Brookings Institution, “Approximately 50 to 66 percent of youth who are in the custody of the juvenile justice system across various types of settings have a mental disorder compared to 15 to 25 percent of youth in the general population.”
A 2004 report from National Mental Health Association that looked at mental health treatment of youth in the prison system breaks this down even further:
“Research indicates that from one-quarter to one-third of incarcerated youth have anxiety or mood disorder diagnoses, nearly half of incarcerated girls meet criteria for post-traumatic stress disorder (PTSD), and up to 19 percent of incarcerated youth may be suicidal. In addition, up to two-thirds of children who have mental illnesses and are involved with the juvenile justice system have co-occurring substance abuse disorders, making their diagnosis and treatment needs more complex.”
In many cases—most particularly in children with depression, PTSD or attention disorders—these mental health problems are not appropriately treated with atypical antipsychotics. In fact, say experts, they may be doing more harm than good. At Mississippi State University, researchers recently found that when used in children, atypical antipsychotic medications are frequently prescribed off label to control disruptive behavior “through sedation rather than targeting actual causes…and lead to many negative side effects with unknown long-term effects.”
What factors drive this serious overuse of antipsychotic medications in troubled kids? Ultimately, it comes down to cold economics. The authors of the Future of Children report write that “state mental health services for youth have been cut back, resulting in insufficient services for mentally ill youth. At the same time, juvenile justice statutes have been amended to reduce the discretion of judges to divert mentally ill youth to treatment even if it can be located. The overall result of this ‘perfect storm’ is that there has been a significant increase in the number of youth entering the juvenile justice system with profound mental health issues—issues that cannot be addressed by the current juvenile justice system.”
In the face of state budget deficits, staff levels of nurses, psychologists and child psychiatrists has been cut at almost all juvenile facilities. So have substance abuse programs. The Youth Today piece refers to an Illinois report’s findings that “mental health services in juvenile facilities are dangerously underfunded and staffed by poorly trained workers. In one facility, the report states, the caseloads are ‘unmanageable and a barrier for meaningful treatment to occur.’ Another facility had a psychiatrist on staff only 12 hours per week, while 98 percent of the facility’s wards were on some form of psychiatric drug.”
Drugging incarcerated kids with strong antipsychotic medications is an inexpensive and effective method for keeping them “restrained” while confined to understaffed correction facilities. It also benefits some of the doctors who prescribe these heavily-promoted drugs. In Part II of the Post’s investigation, Laforgia mines records recently released by drug companies that list payments and gifts to physicians and finds a strong correlation between psychiatrists who work for Florida’s DJJ and receive these gifts and the number of prescriptions they write for kids in custody. “One in three of the psychiatrists who have contracted with the state Department of Juvenile Justice in the past five years has taken speaker fees or gifts from companies that make antipsychotic medications,” writes Laforgia. That one-third of DJJ-associated doctors went on to write more than half of all prescriptions for these drugs—sometimes before they even were approved for any use in children.
In the end, what stands out is the stark disconnect between theory and practice in the overall juvenile justice system. The Office of Juvenile Justice and Delinquency Prevention (OJJDP), part of the U.S. Department of Justice, advocates for programs that emphasize community treatment and monitoring over incarceration. In a recent seven-year study of youths convicted of serious offensives, the agency came to the conclusion that, “incarceration may not be the most appropriate or effective option, even for many of the most serious adolescent offenders. Longer stays in juvenile facilities did not reduce reoffending; institutional placement even raised offending levels in those with the lowest level of offending. Youth who received community-based supervision and aftercare services were more likely to attend school, go to work, and avoid further offending during the 6 months after release, and longer supervision periods increased these benefits.” Another finding; treatment for substance abuse also lowered the rate of recidivism among these troubled teens.
The Federal Advisory Council on Juvenile Justice, a group made up of representatives from every state, provides a comprehensive report each year (here is the link to the 2010 report) with similar recommendations. One that stands out is that states should try to keep kids out of the court system and detention centers in the first place. This includes better coordination between child welfare agencies and the justice department to monitor and intervene with at-risk children before they commit crimes and amending the No Child Left Behind Act to encourage schools to seek alternatives when dealing with disruptive students other than referring them to the juvenile justice system. If suggestions like these sound familiar, it is because they are very similar to those concerning mentally ill adults who end up in the criminal justice system—bouncing back and forth between homelessness, psychiatric facilities, emergency rooms and prisons. The takeaway is that we can no longer separate comprehensive mental health treatment, family and social support and prevention programs from the juvenile justice system.
At the simplest level, the Youth Today report raised awareness to the fact that there is sparse record-keeping of use of psychiatric medication in juvenile detention facilities and lax oversight of these practices, especially in the for-profit centers. This clearly needs to change. Every child entering the correction system must have a diagnosis, access to mental health providers and a treatment plan that actually makes sense. If a child has ADHD or is suffering from post-traumatic stress disorder they should not be taking atypical antipsychotics like Seroquel or Zyprexa—in these cases there is no question that such drugs are being used as “chemical restraints” or “sleeping aids.”
Investigations like the one from the Palm Beach Post are important and could be duplicated by reporters in other states through mining records and data to further document the abuses of “chemical restraint” in both state and privately-run juvenile detention centers. The larger issue raised by these investigations is that we are short-changing the future of many of our children by locking away too many youthful offenders and not offering truly rehabilitative care or services to these most vulnerable of citizens.