Harming the most vulnerable

I really should try to avoid reading articles during breakfast that make my throat close up.  It’s hard enough to choke the food down quickly enough to be on time for work without worrying that I’m going to asphyxiate on my own rage.

This morning’s toast-stopper comes courtesy of the New York Times:

Foster children are being prescribed cocktails of powerful antipsychosis drugs just as frequently as some of the most mentally disabled youngsters on Medicaid, a new study suggests.

The report, published Monday in the journal Pediatrics, is the first to investigate how often youngsters in foster care are given two antipsychotic drugs at once, the authors said. The drugs include Risperdal, Seroquel and Zyprexa — among other so-called major tranquilizers — which were developed for schizophrenia but are now used as all-purpose drugs for almost any psychiatric symptoms.

“The kids in foster care may come from bad homes, but they do not have the sort of complex medical issues that those in the disabled population do,” said Susan dosReis, an associate professor in the University of Maryland School of Pharmacy and the lead author.

I like that catch-all phrase “any psychiatric symptoms.”  Because you know what counts as a “psychiatric symptom”?  Disruptive behavior.  Raise your hand if you think being raised in an unstable environment sufficient to land a child in foster care might contribute significantly to that child’s tendency to behave disruptively.

The online version of Pediatrics hasn’t posted this study yet, and I haven’t received my paper copy in the mail.  I am thus unable to comment on it beyond what is reported in the Times.  Unfortunately, I don’t know if the authors report on why these kids are typically put on these medications, but I’ll lay a solid bet that the majority (probably by a sizable margin) are medicated for the sake of controlling their behaviors.  They’re taking them for the sake of being sedated.

Very few things anger me quite so much as the overprescription of powerful antipsychotic medications to children.  These medications are not benign, and their long-term effects on children are not well-understood.  We already know that they cause significant weight gain, which can lead to further metabolic problems.  They are, however, notably sedating, and so all too frequently a known side effect is mistaken for a clinical benefit, and they’re used to calm unruly children.

It appalls me that these children are placed on these medications, when what they need is a stable home and behavioral interventions.  It makes me livid to read that many of them are on more than one.  Because foster children often go from home to home to home, they often arrive in a new home on a battery of medications that have been started by God knows whom for God knows what reason, and even the best-intentioned of foster parent may have no idea why the child is taking them, or have any notion that they should be stopped.  While I accept that the plural of “anecdote” is not “data,” I’ve certainly seen this happen myself.  One child, newly-arrived at my old practice when she was placed with a new foster mother (who blessedly wanted to take her off of as many medications as possible), was on such a complex regimen that I had to call my best friend from medical school (a child psychiatrist) and get her help in tapering them off safely.

The article’s lede seems to understate things, which are even more egregious than appears at first blush.

Yet among these, it was the foster children who most often got more than one such prescription at the same time: 9.2 percent, versus 6.8 percent among the children on disability, and just 2.5 percent of those in the needy families program. [emphasis added]

Foster children are more likely to get a complex, potentially harmful cocktail of powerful antipsychotic medications than children who are on Mediaid because of mental disabilities, for whom these medications might actually be clinically indicated.  This is an absolute atrocity.  This is bad, harmful, negligent medical care.

Again, since I haven’t yet read the full article there may be information I’m missing.  One little detail that seems to emerge from the Times article is that these medications are apparently being prescribed by psychiatrists, though I wonder if the newspaper isn’t eliding some nuance.  An additional fillip to my underlying ire is how often these medications are prescribed (totally inappropriately, in my opinion) by primary care providers, who have little or no psychiatric training.  In the end, though, it doesn’t matter what kind of doctor is writing out the script if it shouldn’t be written in the first place.

It goes without saying that children in foster care need access to resources that are far too often lacking.  I don’t have any concise answer to the question of how “the system” needs to change, and the supports, providers and therapies available vary widely from location to location.  I would want all of them to have compassionate, insightful caregivers with expertise in childhood behavioral disorders, and for there to be ample access and funding for various different therapies.  And I know that these things are often thin on the ground, and I might as well add an all-expenses-paid luxury tour of Europe’s capitals to my wish list.  Insofar as there is a “solution” to the problems of the foster care system, it is doubtless multi-factorial and likely to be more costly than most states can afford.  But the answer is not to medicate these children into quietude.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. Raise your hand if you think being raised in an unstable environment sufficient to land a child in foster care might contribute significantly to that child’s tendency to behave disruptively.

    It’s worse than that, I’d guess. Ever met a kid who’s never disruptive? (Actually, they’d be the kids to worry about. Something serious is interfering with their normal behavior.) Even kids who are reasonably well-adjusted and successful could be targets for these drugs.

  2. Wonder if it could be in Medicaid’s financial interest to do a few months of home visits which teach parents to deal with behavior problems using positive discipline or ABA or whatever. Apparently, these are very effective, and over time, they’ve got to cost lest than drugs.

  3. Be aware of drugs that potentiate diabetes.
    Seroquel and Eli Lilly Zyprexa Olanzapine issues.

    The use of powerful antipsychotic drugs has increased in children as young as three years old. Weight gain, increases in triglyceride levels and associated risks for diabetes and cardiovascular disease. The average weight gain (adults) over the 12 week study period was the highest for Zyprexa—17 pounds. You’d be hard pressed to gain that kind of weight sport-eating your way through the holidays.One in 145 adults died in clinical trials of those taking the antipsychotic drug Zyprexa.
    This was Lilly’s #1 product $5 billion per year sales,moreover Lilly also make billions more on drugs that treat diabetes.

    — Daniel Haszard Zyprexa victim activist and patient.
    FMI zyprexa-victims(dot)com

  4. Not that I disagree with anything you’ve said here, but may I play policy devil’s advocate for a moment?

    It appalls me that these children are placed on these medications, when what they need is a stable home and behavioral interventions.

    Given the difficulty of finding suitable foster homes for children, and the frequency with which disruptive children get shuffled in and out of foster homes, isn’t it possible that calming them pharmacologically prior to placement could enhance the prospects of keeping the child in a stable home, thus opening up a window for getting them more effective behavioral interventions? That is, if the policy was (which it probably isn’t) to use the drugs on an explicitly temporary basis to create enough stability for them to benefit from more desirable methods?

    My assumption is that a child who’s (understandably) disruptive to a bad home life is less likely to find a stable foster home because their behavior is too hard for many foster parents to deal with, and this leads to them going back home or into state institutions, into another home, then back again, creating instability that exacerbates their disruptiveness and, I am assuming, severely constrains the prospects of them benefiting from behavioral therapies because the underlying problem of instability is still present.

    If that’s the case, is it possible that the risks of medicating children might be acceptable. Please note that I am not downplaying those risks, the reality that we don’t have good data on long-term effects, and the problem that we can’t get that data without purposely exposing some children to the risk. I’m just trying to think as a policy analyst comparing two imperfect policy options.

    • If the system allowed for clear communication between all parties, with medications being prescribed at low doses by experienced providers, and foster parents understood the importance of close monitoring and tapering off the medication as rapidly as possible, then maybe one could argue for sparing, judicious use of these medications.

      Since just about none of the necessary components listed is actually a part of the foster care system as I have observed it (despite the best of intentions by many people involved), the risks of inappropriate, excessive and prolonged medication far outweigh any benefit I can see.

      • I agree with all that. Certainly the current approach cannot be justified, and a carefully designed program with all the elements you mention would be crucial if we were take such a path. And obviously even then we’re taking some real risks with these children.

        I don’t advocate adolescent medication lightly. I’m someone who’s benefited greatly from it, but I worry about whether my adolescent children will need such stuff and, if so, whether it will be safe to give it to them.

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