The Globe and Mail
BEHAVIOUR MANAGEMENT: INVESTIGATION
Nearly half of children in Crown care are medicated
Rising number of psychotropic prescriptions fuels fear drugs are being used as a crutch
Toronto -- Psychotropic drugs are being prescribed to nearly half the Crown wards in a sample of Ontario children's aid societies, kindling fears that the agencies are overusing medication with the province's most vulnerable children.
According to documents obtained by The Globe and Mail under Ontario's Freedom of Information Act, 47 per cent of the Crown wards - children in permanent CAS care - at five randomly picked agencies were prescribed psychotropics last year to treat depression, attention deficit disorder, anxiety and other mental-health problems. And, the wards are diagnosed and medicated far more often than are children in the general population.
"These children have lots of issues and the quickest and easiest way to deal with it is to put them on medication, but it doesn't really deal with the issues," said child psychiatrist Dick Meen, clinical director of Kinark Child and Family Services, the largest children's mental health agency in Ontario.
"In this day and age, particularly in North America, there's a rush for quick fixes. And so a lot of kids, especially those that don't have parents, will get placed on medication in order to keep them under control."
Yet the number of children taking these drugs keeps rising, even in the population at large.
Pharmacies dispensed 51 million prescriptions to Canadians for psychotropic medication last year, a 32-per-cent jump in just four years, according to pharmaceutical information company IMS Health Canada. Prescriptions sold for the class of antidepressants, including Ritalin, most prescribed to children to tackle such disorders as attention deficit hyperactivity disorder (ADHD) rose more than 47 per cent, to 1.87 million last year; a new generation of antipsychotic medication increasingly prescribed to children nearly doubled in the same span, climbing 92 per cent to 8.7 million prescriptions.
And with close to half of Crown wards on psychotropic medication, their numbers are more than triple the rate of drug prescriptions for psychiatric problems among children in general.
With histories of abuse, neglect and loss, children in foster care often bear psychological scars unknown to most of their peers. But without a doting parent in their corner, they are open to hasty diagnoses and heavy-handed prescriptions. Oversight for administering the drugs and watching for side effects is left to often low-paid, inexperienced staff working in privately owned, loosely regulated group homes and to overburdened caseworkers legally bound to visit their charges only once every three months.
Unease over the number of medicated wards of the state is growing: This September, when provincial child advocates convene in Edmonton for their biannual meeting, the use of medication to manage the behaviour of foster children across Canada will be at the top of their agenda.
'whole range of disorders'
Nowhere is concern greater than in Ontario, where the provincial government recently appointed a panel of experts to develop standards of care for administering drugs to children in foster care, group homes and detention centres.
The move was made after the high-profile case last year of a now-13-year-old boy in a group home outside Toronto came to light. The boy was saddled with four serious psychiatric diagnoses, including oppositional defiant disorder and Tourette's syndrome, and doused daily with a cocktail of psychotropic drugs before his grandparents came to his rescue. Now living with his grandparents, he is free of diagnoses and drugs.
Marti McKay is the Toronto child psychologist who, when hired by the local CAS to assess the grandparents' capacity as guardians to the boy, discovered a child so chemically altered that his real character was clouded by the side effects of adult doses of drugs.
"There are lots of other kids like that," said Dr. McKay, one of the experts on the government panel. "If you look at the group homes, it's close to 100 per cent of the kids who are on not just one drug, but on drug cocktails with multiple diagnoses.
"There are too many kids being diagnosed with ... a whole range of disorders that are way out of proportion to the normal population. ... It's just not reasonable to think the children in care would have such overrepresentation in these rather obscure disorders."
The report from a government investigation into the case obtained by The Globe uncovered group home staff untrained in the use and side effects of the psychotropic drugs they were doling out; no requests from the psychiatrist to monitor the boy for problems, and little evidence of efforts to treat the boy's apparent mental-health issues other than with heavy-duty pharmaceuticals.
James Dubray, executive director of the Durham CAS where the boy was a Crown ward, acknowledges that the agency's monitoring of children on medication was lacking.
But it is no small feat, he said, for agencies like his to raise challenging children and adolescents - including some with behaviours so insufferable that their parents turn them over - when there is a chronic shortage of children's mental-health services across Canada and disruptive young people are stranded on waiting lists for psychiatrists and therapies for as long as a year.
With few specialists available, growing numbers of child-welfare workers are turning to family physicians, typically with next to no training in psychiatric disorders and no expertise in the new cutting-edge psychotropic drugs.
"I don't think that's an unfair conclusion," Dr. Dubray allowed. "I find it hard to make a judgment. I just know we tend to see kids for which there are either no resources or their parents can't handle them."
For Judy Finlay, Ontario's chief child advocate, the use of psychotropic drugs is a burning issue.
Since the inquests into the deaths of a handful of troubled adolescents being forcibly restrained in group homes a few years ago - and the tougher regulations on the use of physical restraints that followed - she has observed a growing trend among group homes to turn to chemical restraints to control unruly behaviour.
These children have trauma and loss in their backgrounds and, as they grow older and foster parents can no longer tolerate their behaviour, they are moved to group homes operating on a culture of strict curfews and rules. Here, too often, troubled teenagers live in close quarters, staff turnover is rapid, police visits are not uncommon, and watching television is the usual pastime.
"It's more about behaviour management than it is about intervening into mental health issues," Ms. Finlay said.
"It's the adolescents who are being given medication usually, and it's adolescents who are noncompliant. But they're supposed to be," she added. "That's their job. So as adolescents grow and challenge the system or challenge staff, it's at that time that we begin to medicate them. They are going to be challenging, and medicating isn't the way to help them through adolescence."
In fact, child psychiatrists and physicians say they face a tricky call when confronted with a tormented child or adolescent whose behaviour appears to be the symptom of a disorder that, if not treated with drugs and other therapies, will inevitably grow harder to tame.
The newer drugs are safer and backed by a growing stack of research, and physicians insist they allow some mentally ill children to function normally when nothing else works. Yet many drugs have never been tested on children by the pharmaceutical companies funding most of the research; have been studied for only short periods that fail to measure the impact of prolonged use; and are not formally approved to treat the condition being addressed.
"Just because it's safe and effective in adults doesn't mean it's safe and effective in a young person, and that's one of my concerns about the lack of research in young people," said Stan Kutcher, a child psychiatrist and Sun Life Financial chair in adolescent mental health at the IWK Health Centre in Halifax.
"Young people aren't little adults. They have different physiologies. They have different metabolisms. Their brains react differently. Their bodies react differently to drugs."
And therein lies a "horrible conundrum" for doctors. "I'm uncomfortable with kids being really sick," Dr. Kutcher said, "and I'm uncomfortable with the treatments that we have."
The National Youth in Care Network, an advocacy group for young people raised in the child welfare system, is just completing a three-year study, funded by Health Canada, of psychotropic drug use among children and adolescents in care across the country.
The researchers have found that not only were psychotropic drugs prescribed to a clear majority of the current and former wards interviewed, but most were diagnosed with mental-health disorders by a family doctor, never visited a child psychiatrist or another doctor for a second opinion, and doubted the accuracy of their diagnosis.
A disturbing number, the network's research director, Yolanda Lambe, added, have traded the child-welfare system for a life on the street.
"A lot of people are using drugs now," she said. "There's a lot of homeless young people who have been medicated quite heavily."
Children in Crown care at five randomly selected Ontario agencies taking psychotropics
Psychotropic prescriptions sold to Canadians last year
Antidepressants prescribed to children for attention disorders
Stan Kutcher, a child psychologist and Sun Life Financial Chair in Adolescent Mental Health at the IWK Health Centre in Halifax, estimates that between 2 and 6 per cent of children ages five to seven suffer from mental-health disorders requiring treatment; for early adolescents under 14, the number rises to 7 to 11 per cent; by the late teens, research indicates roughly 18 per cent have diagnosable mental-health issues.
The documents obtained by The Globe and Mail included Crown wards reviews at the Children's Aid Society of Toronto, Toronto Catholic Children's Aid Society, Durham Children's Aid Society, Family and Children's Services of Niagara, and Windsor-Essex Children's Aid Society. The children in permanent care with those agencies accounted for a little more than 18 per cent of the province's roughly 9,400 Crown wards.
Psychotropic drugs most commonly prescribed to children:
Examples are Ritalin, Adderall XR, Biphentin and Concerta.
Used to treat inattention, distractibility, agitation, impulsiveness and hyperactivity.
Approved by Health Canada for use with children.
Doctors in Canada recommended their use to treat children 17 and under an estimated 1,125,000 times in 2006.
Examples are Risperdal, Zyprexa, Seroquel and Clozaril.
Used to treat schizophrenia, bipolar disorder and mania.
Not approved by Health Canada for use with children.
Doctors in Canada recommended their use to treat children 17 and under an estimated 363,000 times in 2006.
SEROTONIN REUPTAKE INHIBITORS
Examples are Prozac, Paxil, Zoloft, Celexa, Luvox and Anafranil.
Used to treat depression, obsessive-compulsive disorder, panic disorder and eating disorders.
Not approved by Health Canada for use with children.
Doctors in Canada recommended their use to treat children 17 and under an estimated 360,000 times in 2006.
Sources: IMS Health Canada, Health Canada
Ritalin, the brand name for methylphenidate hydrochloride, has been the drug of choice to treat children with attention-deficit hyperactivity disorder (ADHD) for nearly 40 years.
Developed by the pharmaceutical company Ciba in 1954, it was initially prescribed to adults as a treatment for depression, chronic fatigue and narcolepsy.
Beginning in the 1960s, the central-nervous-system stimulant began to be prescribed to hyperactive children for its calming effect. In particular, it increased the time children could stay focused on an activity.
During the 1980s, prescriptions in the United States for children really began to climb. Canada wasn't far behind, with the psychotropic drug's popularity soaring in the 1990s. Prescriptions were up 500 per cent from the previous decade.
Pediatricians began to take notice of the worrying trend and recommended in 2000 that Ritalin be prescribed only in very limited circumstances, and, even then, only for as long as necessary.
Worldwide, about 75 per cent of Ritalin prescriptions are for children, with four times as many boys on it as girls.
The Public Health Agency of Canada in 2004 reported that many adolescents were taking Ritalin as a recreational drug to stay awake, to increase attentiveness, to suppress appetite and to get high.
Research out of Atlantic Canada found that about 8.5 per cent of children in Grades 7 to 12 had taken Ritalin for non-medicinal purposes, compared with 5.3 per cent who were prescribed it.