Among the most disturbing allegations against privately operated shelters publicized last week by a Reveal and Texas Tribune investigation was the charge that the Office of Refugee Resettlement “routinely administers children psychotropic drugs without lawful authorization,” according to court filings.
The allegations focus primarily on the Manvel, Texas-based Shiloh Residential Treatment Center, a federally funded multi-use facility that houses detained immigrant children and American children receiving special education services. Immigrant children typically end up in ORR facilities for one of two reasons: the government was unable to locate a sponsor for them, or they’ve been identified as having mental health or behavior problems. At any given time, there are typically more than 200 children in federal custody for such reasons. At the moment, of course, the number is much higher.
At Shiloh, the class-action lawsuit alleges, staff held down immigrant children and injected them with powerful psychotropic drugs without their parents or their consent and, often, without even their knowledge. They also threatened that kids wouldn’t see their parents again unless they did their part to be “medication compliant.”
Dr. Javier Ruíz-Nazario, a psychiatrist at Shiloh who is listed multiple times in the court filings as a prescribing physician, had been practicing without board certification to treat children or adolescents for nearly a decade. According to ProPublica’s Dollars for Docs database, in the three years prior to the allegations against him at Shiloh, Ruíz-Nazario accepted $2,576 from drug companies, including ones that manufacture medicines he allegedly prescribed at Shiloh.
In the lawsuit, one child at Shiloh said he didn’t know his diagnosis or which medications he was on. “No one ever told me that,” he said.
The child said staff would intentionally provoke patients before medicating them. “They made us act violently so then we bad [sic] to be given shots,” he alleged. “The staff would insult us and call us names like ‘son of a whore.’ They often did it in English but I understood some English so I would know what they were saying and get really angry.”
The allegations about Shiloh, concerning overmedicated immigrant kids in a privately operated shelter, are horrifying. They also exist within a tradition. The practice of mistreating emotionally distressed children in U.S. custody is one that goes back as early as the 18th century.
Overmedication is a relatively new way for this to manifest. Antipsychotic drugs have been around since the 1950s, but “until the middle of the 1990s, they were pretty much reserved for people with psychosis,” said Stephen Crystal, co-author of a 2016 Health Affairs study about antipsychotic prescription among kids in foster care.
In the 1990s, drug companies introduced second-generation antipsychotics that initially demonstrated a reduced potential for side effects. By the 2000s, drug company representatives began pushing doctors to prescribe off-label antipsychotics to children, a sales tactic not unlike the aggressive marketing of opioids as safe and nonaddictive during the same period.
Crystal doesn’t consider those parallel marketing strategies to be a coincidence.
“The risks were well-known,” he said. “We’re pathologizing behavior more and turning to drugs for a solution. There is a connection.”
Thomas Mackie, assistant professor at the Rutgers School of Public Health and co-author of the Health Affairs study, said that low reimbursement rates in most Medicaid programs for psychosocial and trauma-specific services also contributed to that rise. When providers are faced with limited availability of first-line mental health services, it’s tempting to turn to antipsychotic medication for their publicly insured patients.
Despite the risks, antipsychotic prescriptions to U.S. children in foster care shot up between 2002 and 2007. The Health Affairs researchers found that antipsychotic prescriptions to kids in foster care far outstripped prescriptions to privately insured children, with 8.9 percent of Medicaid-insured kids in foster care receiving antipsychotic medication in 2010, compared to fewer than 1 percent of privately insured children.
While children in foster care do have higher rates of trauma and behavioral issues than the general population, researchers at Rutgers and Columbia University found that children and youth in foster care have twice the likelihood of being prescribed antipsychotics, after controlling for sociodemographics and diagnostic severity.
“This would suggest that simply being in foster care may increase likelihood of use,” Mackie said.
Crystal emphasized that doctors should not automatically prescribe antipsychotics to kids in foster care.
“The drugs should not be the first-line treatment,” he said. “They should be the last-line treatment.”
According to Dr. Jeffrey Lieberman, a psychiatry professor at Columbia, psychotropic drugs are just the latest development in a long-standing pattern of “controlling agitated, disruptive and aggressive behavior in kids.”
In the 18th and 19th centuries, physical restraints such as straitjackets were considered an acceptable method for subduing emotionally distressed individuals, including children.
While such brute treatment is no longer socially acceptable, pharmacological advances have allowed physicians and psychiatrists to similarly control unruly child patients with medicine.
“The blunt way of describing it is that they were used as pharmacologic straitjackets,” Lieberman said of indiscriminately prescribed psychotropic drugs. “Simply to suppress wayward behavior that was difficult to manage.”
Psychotropic drugs such as Seroquel and Risperdal are approved by the Food and Drug Administration to treat severe mental illnesses like depression, schizophrenia, bipolar disorder and irritability among people with autism. For people with severe mental illness, psychotropic drugs can be necessary, even lifesaving treatments.
However, those drugs aren’t approved for conditions like attention deficit hyperactivity disorder or disruptive behavior disorder, the symptoms of which can include outbursts and defiance of authority. And while off-label use isn’t illegal, it’s not good medicine to administer drugs to treat a symptom, like anger or defiance, without considering the causal factors of that behavior.
Antipsychotics can carry significant side effects, including rapid weight gain, an elevated risk of diabetes, extreme lethargy and tremors. In Shiloh, one boy who was detained says he gained 45 pounds in 60 days after being prescribed a cocktail of psychotropic drugs, according to Leecia Welch, one of the lawyers representing the immigrant kids in the class-action suit.
“These drugs can have profound adverse effects on children’s growing brains and bodies,” Welch said. “Administering psychotropic drugs to children for prolonged periods without procedural safeguards, such as obtaining parental or judicial authorization, needlessly places them at risk.”
It’s unclear why staff are alleged to have been forcibly medicating children at Shiloh. But at best, overmedicating kids in U.S. custody is a misguided reaction to the United States’ chronically overburdened mental health system. At worst, it’s an effort to control kids in custody through sedation, rather than helping them.
“Oftentimes it is easier for adults to give traumatized children pills or injections to address behaviors rather than providing them with the trauma-informed mental health treatment they need,” Welch said.
Once kids in state custody are prescribed antipsychotics, there’s not much incentive to take them off of them. As a child in custody of the Massachusetts Department of Children and Families explained, as part of a report commissioned by the state’s Office of the Child Advocate:
They told me if it ever made me sleepy then they’ll take me off of the [antipsychotic medication]. Cause I’m a school person. I like to go to school. I like to learn and for the simple fact it was making me fall asleep in school I just felt like you’re just taking the fun out of my life because I love school, you’re just taking the one thing I love out of my life. And I would tell the doctor the medications is making me fall asleep in class and my teachers would tell them she’s falling asleep a lot in class and they still wouldn’t take me off the medications.
Instead of turning to drugs as a first resort, a better way to treat a child who has been through a traumatic event would be to remove the child from the stressful stimulus, reassure them and try to build a sense of trust and safety.
The American Academy of Child and Adolescent Psychiatry provides national guidelines for the oversight of prescribing psychotropic drugs to children in state custody, noting that unlike children with mental illnesses from intact families, children in state custody have “no consistent interested party to provide informed consent for their treatment.” In the absence of parental oversight, the AACAP notes that the state has a duty to step in and protect children in custody, while taking care not to reduce access to medication for vulnerable children who legitimately need it. (Children in vulnerable populations not receiving any mental health treatment, including the option of medication treatment, is a separate and concerning problem.)
But for many facilities, understaffing makes it all but impossible to offer increased emotional support to individual children who’ve been through stressful or traumatizing experiences. Faced with few resources and a growing patient load, providers may take the path of least resistance and turn to medication as a stopgap measure.
Not only is it inappropriate to prescribe psychotropic drugs to children who haven’t been diagnosed with a mental illness, but those medications don’t actually treat the underlying trauma they’re presumably being prescribed for. It’s normal for kids ― and adults ― to have fits of heightened emotional reaction tied to memories of their trauma, and those reactions don’t necessarily necessitate medication.
“Medications may be able to calm them somewhat, but they are still affected by the experience,” Lieberman said.
And while it’s bad practice to assume that every child who is apprehended at the border without their parents will be traumatized or damaged, “if they experience really scary and abusive, particularly prolonged conditions in the absence of their parents, it can be traumatizing in a way which is life-changing and enduring,” Lieberman said.
Instead of providing the psychological care and reassurance that Lieberman describes, the pending lawsuit alleges that Shiloh staff sought quick-fix drugs to keep kids under control.
“The root problem is that many children in ORR custody are not receiving trauma-informed care or mental health services in community-based settings,” Welch said. “It suggests that there is a lack of training in appropriate ways of properly de-escalating challenging behaviors.”
The blunt way of describing it is that they were used as pharmacologic straitjackets. Simply to suppress wayward behavior that was difficult to manage. Dr. Jeffrey Lieberman, psychiatry professor at Columbia University
In the case of foster care, lawsuits and legislative action have proven to be effective tools in fighting the mistreatment of children.
Prescription to foster care kids peaked in 2008, after child welfare advocates, federal agencies like the U.S. Children’s Bureau and the Government Accountability Office, and individual states, like Washington, Texas and California, stepped up, precipitating a shift toward greater restraint.
“The net effect of all these actions has led to a shift toward more careful and cautious antipsychotic prescribing in many states,” Crystal said.
In 2016, California passed laws to limit psychotropic drugs prescribed to kids in foster care settings and to monitor high-prescribing doctors, following an investigation by the San Jose Mercury News, which found that nearly a quarter of adolescents in California’s foster care system were receiving psychotropic drugs ― a rate 3.5 times higher than the national average.
“The same standards that were passed through my legislation protecting foster children should be applied to children living in harmful conditions in ORR facilities,” state Sen. Jim Beall (D), who authored one of the California bills, told HuffPost. “Detaining children for too long, denying placement with families and using psychotropic medications for behavioral control in unsafe facilities for children is wrong.”
Crystal stressed that children in ORR facilities have even fewer protections than kids in foster care, since they’re not U.S. citizens.
“It sounds like the feds have created this network of centers without the oversight you would have in the child welfare system,” he said, noting that advocacy and litigation, like the Shiloh lawsuit, are still important roads forward. “Sometimes in America the only time you improve systems is when you go to court.”