Of course some children are being drugged

New York Times reporter Rukmini Callimachi is appalled to learn from an article in her paper that some of the immigrant children being held by the US government are being medicated with psychiatric drugs.

However, my reaction was, “Of course some children are being drugged.”

Why is Callimachi shocked while I am not? Certain psychotropic drugs are often prescribed to patients who do not have the mental disorders for which these medications are approved. These drugs have significant harmful side effects. Therefore, in my view, many of these prescriptions are misuses of the drugs.

So why are these drugs prescribed? Because they have powerful sedative effects, which is why the children are sleeping at their desks. There are high rates of antipsychotic prescriptions in foster care, in nursing homes, and — I will bet — many other institutional settings. The goal of sedation is often not to treat a diagnosed illness but rather to control the behaviour of someone who is institutionalised and difficult to manage.

The many readers or viewers of One Flew Over the Cuckoo’s Nest may imagine that the problem is that these institutions are run by sociopaths like Nurse Ratched who are unable to tolerate happy, free-spirited souls like Randle Patrick McMurphy. I don’t think that’s a common situation, but I have never been committed to a hospital. (Or at least not yet.)

There are situations where institutions that provide long-term care have legitimate concerns about unruly patients. People who have dementia are sometimes disinhibited. They can be aggressive or engage in unwanted sexual behaviours that terrify and endanger their vulnerable co-residents. Institutionalized children have often been exposed to horrific violence and, sometimes, experience paroxysmic anger. Some of these children have minimal self-control and, because they are already institutionalised, have nothing to lose. A young child with a piece of silverware can do a lot of harm.

There are two options here. First, you can physically restrain someone, e.g., by strapping them to a bed. The restraints protect the staff and the institutional residents. But it isn’t therapeutic for the patient.

Or you can use a powerful sedative as a “chemical restraint.” The patient is stupified and becomes docile for an extended period. Sedation may be more humane for the patient and is certainly easier for the institution. Of course, if you can’t or won’t do anything to prevent recurrence of disruptive or threatening behaviour, you will be chronically sedating the patient.

Is there a way to avoid these grim choices? Not completely. So long as severely-impaired people need to be institutionalised, there will be situations where some of them need to be restrained. Desinstitutionalizing these unfortunate souls transfers the risk to a family or to other people living on the streets.

Nevertheless, we can reduce the institutional use of physical or chemical restraints by not institutionalising people who do not need to be institutionalised. One population that comes to mind is normal children who are taken from their parents as hostages to frighten potential immigrants from seeking entry to the US.

For those who must live in institutions, there are ways to reduce the need for physical or chemical restraints. Many long-term care facilities are understaffed or staffed by workers who lack training in managing disinhibited or enraged residents. There is a shortage of specialized facilities for profoundly impaired residents.

However, institutions with humane staffing levels are far more expensive than those relying on chemical restraints. I  support better supervision of long-term care and foster care. Likewise, we should carry out research to find cost-effective ways to manage impaired institutional residents humanely. But do not delude yourself: decent care for vulnerable and disabled children and the elderly will require more spending on the government programs that care for these populations. If you refuse to be taxed to provide better care for these people, you are choosing to sedate them instead.


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