A new study indicates statewide reforms have freed thousands of abused and neglected children from the lasting effects of the most powerful psychiatric drugs, but concerns about other medications persist.
They use the words “zombie,” “a blob” and “drunk” when describing what it felt like to be a kid in foster care, prescribed mind-numbing psychiatric drugs to overcome childhood trauma.
Now, according to a new peer-reviewed study, children in the nation’s largest foster care system are being given powerful antipsychotic medications far less frequently, following a slate of legislative reforms in California, stricter controls on pharmacy dispensing and heightened media attention.
“By reducing these prescriptions for the children who don’t need them, California may have given them more opportunities to thrive,” said Julio Nunes, lead author of the July journal article on the state’s prescribing patterns. “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. That all increases their potential for growth.”
Psychiatric drugs, known broadly as psychotropics, have long been relied on in foster care systems to blunt acting-out behaviors and numb the emotional impacts of childhood trauma. But combinations of multiple drugs, high dosages and the subgroup of medications called antipsychotics can compound the pain. These particularly potent medicines — designed to treat adults with severe mental illnesses — often saddle children with diabetes, irreversible tremors and obesity.
Nunes’ article in the Journal of Child and Adolescent Psychopharmacology shows that over the span of a decade, the number of antipsychotic prescriptions filled for abused and neglected children in California dropped 58% statewide, and 64% in Los Angeles County. The downward trend between 2011 and 2020 held true across every foster care age group, children of varying racial and ethnic backgrounds, and all regions of California. Declines were most pronounced for children younger than 10.
“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. Havens credited the effectiveness of strengthened prescribing rules and guidelines for foster children who are too often overlooked by the medical establishment.
“The treatment for post-traumatic stress disorder-related stuff, and all trauma-related challenges, is psychotherapy — that’s the evidence-based treatment for these kids,” Havens said. “But we also use antipsychotics quite commonly for kids who are just angry, which is despicable.”
Still, much remains unknown about which pharmaceuticals may have replaced antipsychotics, and whether foster children who remain on the drugs for emotional disturbances are being properly screened for side effects.
“It’s great that the rates of antipsychotics have gone down so drastically,” said Sarah Pauter, a former foster youth and senior project manager with the San Francisco-based John Burton Advocates for Youth.
As a 16-year-old in foster care in San Diego County, Pauter was prescribed multiple psychiatric drugs, including heavy doses of antidepressants and mood stabilizers. They pushed the straight-A student who edited her high school newspaper into failing grades and continuation school. Pauter, now 33, went on to earn a master’s degree in public policy from Northwestern University. But the drugs temporarily “derailed” her promising trajectory, she said. She recalls struggling to form sentences and frequently falling asleep in class.
“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 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 by a 2014 Bay Area News Group investigation into the excessive use of psychiatric drugs on California foster children, and the prescribing physicians’ close financial ties to the pharmaceutical industry. The series led to the passage of six state laws, improved tracking of medication use and state medical board oversight, as well as new requirements for judges, social workers, public health nurses, pharmacists and clinicians.
One of those 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 stepped-up measures, the recent study showed that too many foster youth are still being prescribed psychiatric drugs, treatments that have unpredictable side effects and unknown long-term health impacts.
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 described being 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 probation staff didn’t seem concerned. At one point, Watson said she was told she couldn’t leave her room if she didn’t agree to take the medications. She wasn’t able to quit the drugs until her court-appointed attorney stepped in.
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.”
‘Sleep and eat, sleep and eat’
The new findings focus on a dramatic decline in antipsychotics such as Seroquel, Risperdal and Abilify — drugs prescribed for “off-label” use in children that have not been adequately studied for their impacts on the developing brain.
In 2011, there were 78,231 California children in foster care, and more than 7% — or 5,570 kids — were prescribed antipsychotics. In 2020, just 3% of the state’s 68,386 foster children were prescribed the medications, a total of 2,068 children.
What’s more, racial and ethnic disparities in prescribing have been narrowed significantly since 2011: Black, Latino, white, Asian and Pacific Island and Native American youth all saw declines between 38% and 59%.
While antipsychotic use is down considerably among the state’s foster children, other problematic trends have emerged. Nearly half of those who continued receiving antipsychotic drugs were not properly monitored for side effects. The lack of testing for things like blood glucose and cholesterol levels represents a “concerning” lack of required medical oversight, the researchers noted.
The use of psychotropics of all types — mood stabilizers, antidepressants and stimulants — appears to have mostly held steady, at more than 12% of foster children. That rate is more than 2.6 times the rate of prescriptions in the general population, according to the California Child Welfare Indicators Project.
To be sure, child psychiatrists, service providers and even some former foster youth say medications may sometimes be appropriate to help children living with deep emotional pain.
Los Angeles child psychiatrist Robert Holloway said for certain children, antipsychotics “can be very valuable.” He described the decrease in prescriptions for foster youth as a sign that legislative changes, as well as a shifting medical consensus, has made a difference.
Yet to more fully gauge California’s progress, he added, 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 until we know more about the well-being of these kids,” Holloway said.
A half-dozen medical scholars who reviewed the recent findings noted another concern: Under the spotlight of more public scrutiny and system oversight, child psychiatrists may have simply swapped antipsychotics for other types of psychiatric drugs and combinations of multiple drugs, which have their own health hazards.
“A lot of children may have had antipsychotic medication changed to something else,” said Nunes, a Yale University School of Medicine resident psychiatrist. “The big problem with data availability right now is we don’t know what that something else is.”
One widely cited expert on the topic who reviewed the recent pharmacology study suggested “polypharmacy” — or the use of multiple powerful drugs — might be replacing antipsychotics.
“This did not assure me that California has made a major advance. The management of medications in foster care, above all, is a wildly difficult and out-of-control situation,” said Julie Zito, professor of pharmacy and psychiatry at the University of Maryland. “I take my hat off if they are really trying to make medication regimens safer and more appropriate. But the fundamental question is, what does the polypharmacy picture look like?”
‘Experimenting’ on kids
Nunes and his colleagues set out to study psychotropic use among foster youth following growing public concern. They also conducted what is believed to be the first research study analyzing California’s numerous strategies to deter and better monitor the drugs.
The state began tightening its control over psychotropic prescriptions for all children receiving Medi-Cal in 2006. It later tightened controls over prescriptions for kids younger than 5, and those prescribed antipsychotics and multiple meds. Beginning in 2015 and 2016, increased court oversight and checks on pharmacy dispensing required even greater justification before prescriptions could be filled for foster children.
Former presiding juvenile court judge Michael Nash, now executive director of the Los Angeles County Office of Child Protection, has long been tracking the use of psychotropic drugs in foster care. He said despite the steep declines in recent years, the issue needs to be “kept on our radar continuously.”
Nash said psychotropic medications can be helpful for some foster youth, but also “dangerous,” particularly those drugs that are not approved by the Food and Drug Administration for use on children. There is also scant understanding of the drugs’ long-term effect on brain development, he noted, and the trial-and-error method of prescribing the right drug and dosage can be difficult to monitor and endure.
“When we use psychotropic medications on children, we’re experimenting on every kid,” Nash said. “To the extent that we’re going to use psychotropic medications with children, we have to make sure that they are being used for legitimate treatment purposes, as opposed to just trying to control their behavior.
Former San Diego foster youth Azucena Ravazula said she started taking a mix of psychotropics at age 11. As a child, she felt she couldn’t express her qualms about the medications, or how they negatively impacted her. For about three years, Ravazula said she felt powerless and inert on the drugs, “like a blob.”
But she’s 26 now, and can speak out. She described getting the courage to rebel in her teenage years, and flushing her meds down the toilet.
“Being in the system, you’re kind of hush-hushed by the adults around you,” she said. “You can’t really speak up when they make decisions about what they’re putting into your body.”
Ravazula said she ended up in juvenile hall and a group home in San Diego, before finding refuge with an understanding foster mother. And looking back now, repercussions of her drugged youth linger. “You feel like you have empty holes in your head,” she said.
The new research underscores this experience.
“The risk-benefit ratio for the use of antipsychotics may not be in the best interest of foster youth, particularly when other trauma-informed multidisciplinary interventions, such as psychotherapy, may be more effective but are frequently inaccessible to this population,” the study authors state.
And although California law prohibits the use of psychiatric drugs for the purpose of chemical restraint or discipline — except when necessary in psychiatric emergencies — psychotropic medications can be used coercively in the foster care system. In 2015, for example, former foster youth testified before the state Senate that they’d been kicked out of residential treatment centers for refusing medications.
The overprescribing results from 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,” Nunes and his coauthors wrote.
Youth advocate Pauter said despite California’s widespread reforms, the new research “raises more questions than it answers.” California has not provided data to show, for instance, whether doctors are trying therapy before they prescribe meds.
“They can’t show that foster youth are actually being given the services that they need,” she said. “What we’ve heard so often from young people in foster care is that prescriptions should never be a first line of defense, that they wanted to have other non-pharmacological interventions first, before medications were introduced.”
Ravazula found the therapy that worked for her at a horse ranch in El Cajon. Riding saddleback, brushing manes, or just sitting in stillness by the towering animals, gave her a sense of calm.
“With horses, there’s an instant connection, instant love,” she said. “It gets you out of your comfort zone, out of the deep holes that you’ve developed from the trauma from foster homes and psych meds and everything you can think of.”
Her favorite equine companion is a statuesque black steed named Prince. Ravazula ended regular sessions at the ranch earlier this year, but she still calls its owner to check in when she needs a break from city life.
“The best part is that it’s always your choice to do whatever you want with the horse,” Ravazula said. “No one else gets to control anything.”