Sedating Kids in Foster Care with Antipsychotics

Wall Street Journal

Overseen by state and local governments, foster care provides temporary placement for minors unable to remain in their own homes. They can live in individual foster homes, in group homes, or other institutional settings. Nationwide, there were approximately 400,000 children in foster care in 2012, according to the Department of Health and Human Services.

Antipsychotics, drugs dispensed for a broad array of diagnoses, have ignited a wave of debate—most recently over their use in poor children and the billions that they cost the Medicaid and Medicare systems annually.

Most scrutiny centers on a new class of antipsychotics sold under such brand names as Abilify, Seroquel, Risperdal and Zyprexa.

Based on 2009 data from Medicaid and private insurers, Stephen Crystal, a professor of health-services research at Rutgers University, estimates that 12% to 13% of kids in foster care take these medicines. That compares with about 2% for children on Medicaid but not in foster care and about 1% for those with private insurance.

While originally hailed as safer and more tolerable than predecessor drugs such as Thorazine and Haldol, the newer generation of antipsychotics, often called atypicals, has spawned a growing body of research about potential side effects. These, say researchers, can include sudden and severe weight gain, increased risk for diabetes and movement disorders.

Atypicals, with their strong sedative powers, were originally intended for the narrow segment of adults with psychotic conditions like schizophrenia.

The Food and Drug Administration only sanctions their use for kids diagnosed with schizophrenia and conditions such as bipolar disorder and irritability associated with autism. But physicians can also prescribe these medicines "off label" to combat behavioral issues in children—some as young as two years old.

Some doctors stress that the drugs are helpful in treating children with certain aggression and behavior illnesses. Yet many are concerned that the use of antipsychotic drugs, particularly among those in custodial care, has gone too far.

According to Prof. Crystal's research, the largest diagnostic groups receiving the drugs in foster-care in 2009 were those with disruptive-behavioral disorders and attention-deficit/hyperactive disorders.

"These diagnoses involve difficulty focusing attention or controlling behavior—but that is different from not being in touch with reality," a key element of psychosis, he says.

To be sure, some doctors see considerable value in the use of antipsychotics on children in custodial care. Dr. Christoph Correll, professor of psychiatry at Hofstra University's Zucker Hillside Hospital, maintains that antipsychotics can effectively combat the violent, aggressive behavior some foster kids display. The drugs "generally work fast, which is often desired when kids are at risk of being suspended from school for their behaviors," says Dr. Correll. "In these situations, having to wait for a therapy appointment is not an option." [Let's be clear that this is merely managing behavior by administering a heavily sedating drug, and not anything therapeutic.]

The popularity of such drugs helps to account for their blockbuster sales. In 2011, antipsychotics rang up $18.5 billion in U.S. revenues, according IMS Health, rising from $12.9 billion in 2007. Sales dipped in 2012 as cheaper generics came on the market.

Of all prescription drugs sold in the U.S., Otsuka Pharmaceutical Co.'s Abilify boasts the biggest sales by dollar, ringing up $5.87 billion in sales in 2012, according to IMS Health.

In September, the American Psychiatric Association urged its members to prescribe antipsychotics only to kids with serious psychotic disorders.

Fifty years from now, I sincerely hope that the abnormal psych textbooks treat our society's widespread drugging of children with as much contempt as we regard the forced sterilization of Carrie Buck.