Category: Daniel Engber

https://slate.com/technology/2018/08/immigrant-children-abuse-drugged-shiloh-treatment-center.html

Daniel Engber reports for Slate:

A federal court has given the Trump administration until Friday, Aug. 10, to figure out a plan for the 28 immigrant children still detained at the Shiloh Treatment Center in southeast Texas. Any child who is not deemed to pose “a risk of harm to self or others” must be transferred to a less restrictive facility, per Judge Dolly Gee’s July 30 ruling in a lawsuit filed earlier this year. She also addressed the lawsuit’s claims that residents at Shiloh have been given forced injections and prescribed antidepressants, mood stabilizers, and antipsychotic drugs without consent. The government must stop this practice, she determined, and make sure that psychotropic drugs are given to detainees at Shiloh only in accordance with Texas child welfare laws and regulations.

For weeks now, this misuse of psychiatric medications has been cited as a prime example of the White House’s “despicable,” “reprehensible,” “inhumane and unconscionable” border policies. “President Donald Trump’s zero tolerance policy stands to create a zombie army of children forcibly injected with medications,” said the article from the Center for Investigative Reporting that first brought the allegations to light. “The president has to be ordered not to give children psychotropic drugs, but I’m the one that’s tripping?” one Democratic candidate for Congress said a few days ago, in defending progressives’ call to defund U.S. Immigration and Customs Enforcement.

The standard gloss on this medication scandal—that the Trump administration isn’t merely ripping children from their parents but turning all those children’s brains to mush—is substantially misleading. It makes it sound as though the problem was created by our current president when the blame could just as well be placed on the Obama administration. Unaccompanied immigrant children first arrived at the Shiloh Treatment Center in 2009, according to the Center for Investigative Reporting, despite the fact that three children had already died at Shiloh and affiliated centers while being physically restrained by staffers. These were not the only horrific incidents on record. Another time, for example, staff encouraged a group of girls with cognitive disabilities to fight each other gladiator-style for after-school snacks. And while Trump is now responsible for the children in federal custody, and certain medication-related abuses appear to have continued under his watch, most of the cases of abuse included in the lawsuit occurred before he set foot in the Oval Office.

If a child can be diagnosed with post-traumatic stress disorder, then medications aren’t likely to be the most useful form of treatment.

The suspect framing of the Shiloh scandal as a cause for partisan anti-Trump outrage also serves to minimize the problem. When commentators link the overmedication of child immigrants to Trump’s zero tolerance policy at the border, they imply that the children who were forcibly separated from their parents earlier this year are the only ones at risk for this abuse—or, at the very least, that these kids are at higher risk than others in residential treatment. That’s wrong. The 2,500 kids subject to family separation are just a subset of the children held around the country by the Office of Refugee Resettlement. ORR already oversees the placement of some 10,000 minors who arrived at the border on their own, without parents or guardians—and the Shiloh Treatment Center has been housing, treating, and potentially abusing detainees from this larger population for about a decade now.

But even that doesn’t capture the full scale of the problem, which affects not just immigrants but kids throughout the nation’s child welfare system. The court exhibits from the recent lawsuit suggest a scene out of One Flew Over the Cuckoo’s Nest: In addition to receiving forced injections of antipsychotic drugs to calm them down, former residents say they were dosed with as many as nine different pills at a time without being told what they were taking or why. These medications were allegedly prescribed without consulting the children’s parents or their other adult relatives or otherwise securing a court order. Children who refused to swallow their pills, the lawsuit says, were physically made to do so or were coerced in other ways. “They told me … that the only way I could get out of Shiloh was if I took the pills,” one child explained. “I have not refused taking the pills because I was told that … would make me stay at Shiloh longer,” said another.

As awful as these details sound, they’re not unique. Experts on the use of psychotropic drugs in foster care and residential treatment settings say overmedication is widespread. Studies find that foster kids are given psychotropic drugs at least twice as often as other children served by Medicaid, despite a lack of solid evidence for these drugs’ efficacy in children and little knowledge of what long-term hazards they might pose to developing brains. (Most such medications are FDA-approved only for adults, so their use with children is off-label.)

The prescription of several different psychotropic drugs to children at the same time doesn’t represent some new perversion of psychiatry cooked up by the Trump administration or put in place by reckless doctors at a converted trailer park in Texas. Rather, “polypharmacy” is a mainstream approach to medicating children in residential treatment settings. In responding to the recent lawsuit, an ORR official informed the court that Shiloh follows Texas state guidelinesfor the use of such drugs in foster care—which means, she said, that they “strive to use no more than four [psychotropic] medications concurrently.” Again, there’s a lack of data to support this standard practice. “Very few studies have shown safety and efficacy for two or more psychotropics used concurrently in children, and none, virtually, have shown safety or efficacy using three or more,” says Erin Barnett, an assistant professor of psychiatry at Dartmouth who studies evidence-based practices for traumatized children. “Yet this kind of bad treatment is going on all over the country.”

There are some specific ways in which the methods reportedly used by Shiloh Treatment Center do stand apart. Even when a given child’s parents were reachable, the lawsuit says, the center did not bother to reach out to them regarding the use of drugs. (This apparent indifference to informed consent provoked a major portion of the judge’s recent ruling.) In practice, though, adherence to the rules on consent does not prevent the overuse of medications in residential treatment settings. Many parents and guardians acquiesce to polypharmacy when it’s recommended by a doctor, and officials tasked with overseeing wards of the state may also sign off on a smorgasbord of psychotropics provided that a child has been diagnosed with several different mental health conditions.

It’s also not enough to have a relative’s informed consent when treating psychiatric issues in these settings. The kids themselves should also give “assent” to treatment, which means they’re willing to accept the drugs. That’s often not the case in residential treatment settings, though. Kids who have been placed in these facilities tend to have long, complicated histories of treatment and may be suspicious of whatever care they’re being offered. When they do refuse their medication, their behavior is often chalked up to emotional problems—an “oppositional defiant disorder,” perhaps. According to both Barnett and Robert Foltz, a clinical psychologist and member of the board for the Association of Children’s Residential Centers, health care providers will at times cajole these children into taking meds, perhaps by threatening to “remove their privs”—which is to say, depriving them of activities they enjoy. Barnett cites a study of 50 adolescents taking psychotropic drugs, which found that nearly half reported feeling “forced or pushed” to take their medications.

The use of psychotropic drugs with kids detained at the border raises unique concerns. For one thing, we might guess that these children’s mental health issues stem, in large part, from whatever troubling events led them to leave their home countries, combined with the stress of being held in custody and—for those detained this year under Trump’s family-separation policy—the trauma of having been pried away from their parents. If it is possible to identify clear environmental causes of their distress, or if a child can be diagnosed with post-traumatic stress disorder, then medications—even when they’re ethically applied—aren’t likely to be the most useful form of treatment. According to Foltz, psychotropic drugs barely work for PTSD and are not considered front-line treatments; the American Academy of Child and Adolescent Psychiatry recommends cognitive behavioral therapy instead. Another problem arises from the fact that, in most cases, health care providers for these children won’t have access to their patients’ detailed case histories, so whatever psychiatric diagnoses they make will be off the cuff.