Forcing Psych Meds on Detained Children Perpetuates Distrust About Mental Health Care
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Here at our psychiatric clinic in Boston, we treat asylum seekers and refugees every week. We have evaluated adolescents fleeing the scourge of gang violence in their home countries as a part of their legal proceedings, and witnessed the immense suffering of families torn apart.
We find the current child separation strategies by the Trump administration to be fertile ground for significant human rights abuses and, among other concerns, we are deeply disturbed that separated children are forcibly being given psychotropic medications while in government detention centers. According to a court brief, children were forced to take medications including benzodiazepine tranquilizers, which have addictive potential, as well as mood stabilizers generally reserved to treat bipolar disorder, and antipsychotic medications.
The ruling of a federal judge on Monday that shelters cannot administer such drugs without parental consent should serve as a warning that the perverse use of mental health treatment on children without consent not only affects their mental health in the moment, but will impact people of color seeking mental health treatment in the future.
Children fleeing Central America are victims of structural violence—ways in which larger social structures oppress individuals. The reasons their families are fleeing to the United States are inextricably linked to US foreign economic and criminal justice policies in Central America; not just a desire to come to the US. Not only have these children experienced tremendous violence in their countries of origin, and often en route to the US, but our government is compounding matters by its policies and actions.
And so, to label grief, anger, sadness, nightmares, and all the other symptoms these children might be exhibiting as psychiatric illness that needs to be coercively treated is both unethical and immoral. Pathologizing their reactions to very abnormal circumstances—seemingly unlawful detention in inhumane circumstances—often is a means of clouding the true source of the illness, which is the detention itself.
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The case of forcibly separated children in immigration detention, a type of what the French anthropologist Michel Foucault called “biopower,” is wielded by the state in the form of using psychotropics to quell their reaction to the heinous circumstance. Medications like antipsychotics are not meant—nor are they approved for—kids who are distraught because they have been forcibly separated from their families.
Given that these medications are being prescribed to children who’ve been forcibly removed from their parents, there is no informed consent for administering such medications. Even if the children themselves agree to take the drugs, in most states they are not able to consent to treatment because they’re minors. In the case of these children who are in federal custody, neither the children are being asked for their assent nor are their parents are not being asked for consent. Ethics rules from the American Psychiatric Association (APA) highlight the importance of practicing informed consent; parents and guardians play an important role in providing this consent, and even children have the ability to refuse psychiatric treatment.
Alas, the brief submitted to the courts on behalf of the children report that they were were being coerced into taking medication. One child, Javier C., described in the brief, “I took nine pills in the morning and seven in the evening. I don’t know what medications I was taking...”
Even more troubling is that once children were in the treatment facilities, such as at Shiloh in Texas, many were told that they would lose privileges or wouldn’t be allowed to leave unless they complied with the staff directive to take medications. This harkens back to the human rights abuses of the psychiatric asylum era that led to the shuttering of those mental asylums. And it is a fundamental infringement of child human rights.
There are numerous child protection statutes in international law that are being violated here. The United States is the only country in the world that isn’t party to the international Convention on the Rights of the Child, largely due to opposition of Republican lawmakers around concerns around it infringing on American sovereignty. But America is party to the International Covenant on Civil and Political Rights, which recognizes that “family is the natural and fundamental group unit of society and is entitled to protection by society and the State.”
There has been concern over possible overprescribing of antipsychotics for young children in the general population—more often for aggressive behavior rather than what they are actually meant for, which is psychotic illnesses. In the court affidavit from Shiloh Detention Center in Texas, some children were being prescribed heavy-duty psychiatric medications—as a means to chemically straight jacket and silence them to some extent. But the staff are not treating the actual problem and alleviating the cause of the pain and suffering.
Given the serious potential side effects medications like mood stabilizers and antipsychotics can have on developing minds, expert evaluation and diagnosis is needed for children and adolescents. This requires understanding not just their biological contributions to mental illness, but the psychological impact of separation, and the utmost care needs to be taken to ensure that these medications are prescribed both carefully and with the full consent of everyone involved.
Without parents to protect the child, the state failed to do its duty as parens patriae, a doctrine that gives the government power to make decisions on behalf of the child if the parents cannot. And the stories are everywhere: an eight-year-old boy awaiting psychiatric admission, pediatricians seeing the horrors that children face at the border, children held in detention. The American Academy of Pediatrics review of Department of Homeland Security detention centers found them to be lacking and concluded: “The Department of Homeland Security facilities do not meet the basic standards for the care of children in residential settings. The recommendations in this statement call for limited exposure of any child to current Department of Homeland Security facilities.”
We are witnessing our own government engaged in pulling families apart and now haphazardly attempting to unite many of them. These children have been subjected to immense trauma. Children do not solely experience trauma in their country of origin but we have seen that the perilous journey to the United States has its attendant traumatic experiences, as does crossing into the US and, if apprehended, the detention setting is also inherently traumatic.
As the American Academy of Child and Adolescent Psychiatry warns, “When children experience sudden separation from one or both parents, especially under frightening, unpredictable, and/or chaotic circumstances, they are at heightened risk for developing post-traumatic stress disorder (PTSD), anxiety, depression, and other trauma-related reactions that may last for the rest of their lives.”
We fear that with the trauma these children have endured, they will be reluctant to engage with the mental health care system certainly in the short term, but perhaps throughout their lives. And beyond harming these particular immigrant children, we fear that as these stories of coercion and abuse by mental health professionals become known, many people of color or people who are themselves disenfranchised in some way will come to distrust mental health care and not seek help when they need it—a problem that is already persistent in many communities.
This could further widen gaps in care: The data are consistent that access and completion of mental health treatment for minority children is lower than for white children. Furthermore, for marginalized youth, medications like antipsychotics are often started before psychosocial interventions are offered.
While we believe psychiatry has much to offer for children and adolescents who are suffering, the prescription for these immigrant children is simple: expeditiously reunite them with their parents or guardians. The overwhelming likelihood is that they are grieving because they were forcibly taken from their loved ones, not because they are mentally ill.
The trauma children endure now will have a lasting impact on their psyche. And not adequately treating their mental suffering is a stain on the American psyche. In addition to reuniting families, there is much work to be done so that children, once released from detention, have access to the care they desperately need. Medications alone will not help them heal. In the midst of xenophobic vitriol, children’s lives are at stake—silencing them with medications is malpractice.
Nikhil “Sunny” Patel is a third-year psychiatry resident at Cambridge Health Alliance and a clinical fellow in psychiatry at Harvard Medical School.
J. Wesley “Wes” Boyd is an associate professor of psychiatry at Harvard Medical School and a faculty member in the Harvard Medical School Center for Bioethics. He is a staff psychiatrist at Cambridge Health Alliance (CHA) and is the co-founder and co-director of the Global Health and Human Rights Clinic at CHA.
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