How do you handle a really difficult child or youth? A child prone to uncontrollable rages, a child who is violent against his or her peers in a frighteningly unpredictable way. What do you do if the child is being raised by parents with limited control over their impulses, with a truncated sense of responsibility for the child, and who discipline the child with a wild savagery? Parents who may not even be present much of the time? How do protect such a child from harm?
Here are some things we should do. If the child is from a disordered home -- this is not always the case -- we should see what can be done to help the parents sort out their employment problems, their housing, their substance abuse, and their disordered characters. We should get them some training in effective parenting. We should look carefully to be sure that the child is not suffering physically, for example, from the chronic pain of abscessed teeth. We should get the child with a therapist who can train him or her in effective strategies to manage negative affect and interpersonal conflict. If necessary, we should place the child in therapeutic residential care.
These things rarely happen, because these services are expensive. Increasingly, what we do instead is sedate these children with powerful antipsychotic drugs. Antipsychotics are expensive as drugs go, but they cost less than mental health care professionals or residential therapy centres. And they make the problem go away. Sort of.
Using data from the National Ambulatory Medical Care Survey, Mark Olfson and his colleagues report the trends in the prescriptions of antipsychotics in youths and adults (where youth means 20 years old or younger). Looking from the period from 1993-1998 to 2005-2009, there has been an almost seven-fold increase in the proportion of medical visits for children that involve an antipsychotic prescription (see, the graph, prescriptions of antipsychotics for adults have doubled over the same period.) This is not because antipsychotics are being used more extensively in the treatment of psychosis: that hasn't changed. What is happening is that antipsychotics are being used more frequently with children with no psychotic disorder (a greater than seven-fold increase).
Antipsychotics do not teach interpersonal skills. They do not, to my knowledge, increase the child's ability to modulate emotions when they are not sedated. Antipsychotics are powerful tranquilizers; so they make certain problems go away. When used to quell a violent patient on a ward, they are referred to, without irony, as "chemical restraints."
Antipsychotics have extensive side effects: they impair movement, they promote rapid weight gain, and they lead to metabolic disorder and diabetes. The use of these drugs is too new for us to be certain of the long term effects on the development of children's brains and bodies, but the initial evidence suggests that the damage may be extensive. When psychiatrists use these drugs, they rarely test for these side effects.
Antipsychotics are typically prescribed without any particular plan for how or when they will be discontinued. Similarly, it seems that we have come to this strategy for managing difficult children without any plan for discontinuing it. Will we continue to sedate them through adulthood? Is there some point where the rapid growth in the use of antipsychotics even slows down? Do we intend to keep an increasingly proportion of the population chemically restrained for their whole lives?
Why are antipsychotic prescriptions to children increasing? In part because they have been pushed by pharmaceutical manufacturers, often using deception. But largely because we are unwilling to pay the cost of providing good care.