California has dramatically curbed its use of antipsychotic medication to control emotionally troubled foster children, according to a new study, raising hopes of a changing culture in the years since a Bay Area News Group investigation exposed the rampant use of those powerful drugs.
Researchers found a 58% drop in prescriptions of antipsychotics – the most powerful and concerning psychiatric drugs – for the state’s abused and neglected children over the span of a decade, although the use of all drugs held steady. The sharp decline for antipsychotics between 2011 and 2020 held true across every foster care age group, children of all racial and ethnic backgrounds, and all regions of California, according to the study published in the Journal of Child and Adolescent Psychopharmacology.
Julio Nunes, a Yale University resident psychiatrist and lead author of the study, called the findings – and their impact – heartening: Reducing medication for children who don’t need it, he said, gives them more opportunities to thrive.
“If they are not numbed, they can pay more attention in school and with friends, and have more meaningful conversations about their trauma with trusted professionals,” Nunes said. “That all increases their potential for growth.”
In the 2014 series “Drugging Our Kids,” the Bay Area News Group highlighted the state foster care system’s reliance on psychiatric medications to blunt disruptive behavior and the impacts of trauma on children wrenched from their families.
But high dosages and combinations of multiple psychiatric drugs can cause more problems than they solve. Antipsychotics – designed to treat adults with severe mental illnesses – not only daze children into a stupor, these medications often saddle them with diabetes, obesity and irreversible tremors.
In 2011, 7% of the 78,231 California children in foster care – or 5,570 kids – were prescribed antipsychotics. But in 2020, just 3% of the state’s 68,386 foster children were given the medications, a total of 2,068 children.
The drop was especially pronounced for children younger than 10. What’s more, racial and ethnic disparities in prescribing have been nearly eliminated since 2011: Black, Latino, White, Asian and Pacific Island and Native American youth all saw declines between 38% and 59%.
Not all of the news was positive: Nearly half of the foster youth who continued receiving antipsychotic drugs were not properly monitored for the drugs’ side effects. The lack of testing for things like spikes in blood glucose and cholesterol levels represented a “concerning” lack of required medical oversight, Nunes and his research team found.
Still, child psychiatrists and former foster youth were encouraged by the overall trend.
“This is a powerful study,” said Jennifer Havens, chair of the Department of Child and Adolescent Psychiatry at New York University’s Grossman School of Medicine, who credited the effectiveness of California’s strengthened prescribing rules and guidelines for foster children who are too often overlooked by the medical establishment.
“It’s great that the rates of antipsychotics have gone down so drastically,” said Sarah Pauter, 33, a former foster youth who now serves as a senior project manager focused on improving graduation rates among foster youth with the San Francisco-based John Burton Advocates for Youth.
But both Havens and Pauter said another finding in the study raised a troubling question: Are physicians simply replacing antipsychotics with other drugs that also have harmful side effects?
The use of psychiatric medications of all types – including mood stabilizers, antidepressants and stimulants – appears to have mostly remained flat over the decade, at more than 12% of all foster children. That’s more than 2.6 times the rate of the general population, according to state data.
Pauter knows from experience how debilitating those other drugs can be.
As a 16-year-old in San Diego County, she was a straight-A student and editor of her school newspaper. But she was reeling from a failed reunification with her long-absent mother when doctors prescribed her heavy doses of antidepressants and mood stabilizers. Numbed by the medication, she remembers struggling to form sentences and frequently falling asleep in class and was soon failing school.
She blames the drugs for derailing her academic path, but she persevered and eventually earned a master’s degree in public policy from Northwestern University.
“Across the board, regardless of the type of medication,” she said, “we need to make sure that other intensive, appropriate mental health services are always being offered before medication.”
A spokesperson for California’s Department of Social Services, which oversees the foster care system, declined to comment on the recent study, instead highlighting the state’s efforts “aimed at decreasing the utilization of psychotropic medications and strengthening oversight and monitoring.”
State officials were prompted to act after the Bay Area News Group investigation led to a slate of legislative reforms that improved how officials tracked medication use and doctors’ prescribing practices, along with new requirements for judges, social workers, public health nurses, pharmacists and clinicians.
The news organization’s series revealed that nearly 1 out of every 4 adolescents in California’s foster care system – and 15% of all kids – received some type of psychiatric drug, often medication that was not approved for children. It found the state’s most prolific prescribers were responsible about half of the time when a foster child received a powerful antipsychotic. The series also showed those high prescribers often had close ties to pharmaceutical companies manufacturing the drugs.
While the reforms could be putting a chill on over-prescribers, the state’s medical board has yet to crack down on any doctors under scrutiny.
One of the bills, passed in 2016, required the Medical Board of California to sanction doctors who over-prescribed psychiatric drugs to foster youth. According to a medical board spokesperson, 17 physicians have been reported under this law, but as of Aug. 25, none have been disciplined.
Mary Watson, a former Alameda County foster youth now living in San Leandro, said despite the state’s stepped-up efforts, the recent study showed that too many foster youths are still being prescribed psychiatric drugs.
When Watson was 16, she said she was detained at the county juvenile hall after running away from a series of foster homes. While locked up, she was put on an antidepressant and anti-anxiety medications that led to weight gain, drowsiness and terrifying hallucinations that kept her awake for days on end.
When she complained about the side effects, Watson said the probation staff didn’t seem concerned. At one point, Watson said she was told she couldn’t even leave her room if she didn’t agree to take the medications.
Watson, now 27, said she ended up feeling powerless: “They always try to make it seem like you don’t know what you need or you don’t know how you really feel.”
She wasn’t able to quit the drugs until her court-appointed attorney stepped in.
Nunes and his study co-authors found there are still many reasons for overprescribing medications, including a “lack of understanding of the effects of childhood trauma, caregiver demand for medication to manage disruptive behaviors, lack of pediatric mental health resources, and misdiagnosis of trauma symptoms as mental health disorders.”
Los Angeles child psychiatrist Robert Holloway agreed with other experts that legislative changes, as well as a changing medical consensus, had likely driven the decrease in antipsychotic prescriptions.
But he is still a believer that for certain children, the medications “can be very valuable.”
To fully gauge California’s progress, he said, more information is needed about how young people fared without the drugs, and whether there has been an increase in hospitalizations and incarceration.
“The jury’s out,” Holloway said, “until we know more about the well-being of these kids.”
This story is being co-published with The Imprint, a national nonprofit news outlet covering child welfare and youth justice. Jeremy Loudenback and Michael Fitzgerald are staff writers for The Imprint. They can be reached at firstname.lastname@example.org and email@example.com.