The “Wild West” of childhood psychiatric prescriptions

At age 11, Bradley Sonnenberg was diagnosed with anxiety and depression. He was prescribed a little green capsule taken once daily. To his mother, Andrea, the prospect of her son getting better outweighed the potential risks of starting a prescription at such a young age. But it was not a decision she took lightly. 

Five years later, Bradley’s mental health declined further. Another pill was introduced to his regimen. As her son grew older, the cascade of medications became a blur, Andrea says. When various symptoms and side effects became debilitating, he was given even more medications. She grew worried and asked Bradley’s doctor why he was on two drugs that treated the same condition. “Oh, well, you’ll need to ask his neurologist that question,” was the frank response. But his neurologist didn’t have a clear answer either, assuring her the drug regimen was fine.

At 19, Bradley was given highly addictive benzodiazepines as his condition worsened. His mother’s concern mounted, but she was again advised that the drugs would give him much-needed relief. “You trust the psychiatrist, but I just knew that it wasn’t a good idea when he started the benzos. I was nervous — it felt like a Band-Aid, not a solution,” she says.

One night, Bradley wasn’t feeling well, so he took Advil and drank a Red Bull before heading to bed. Bradley was living away from home but talked with his family regularly. He didn’t answer a phone call from his father at 9 p.m., which was unusual, Andrea recalls. 

Bradley died in his sleep that night. The cause of his death: drug interactions, the coroner’s report stated. Although Bradley needed treatment, the number of medications overwhelmed him, Andrea says. “There was not a drug in his body that had not been prescribed to him.” 

Bradley was a son, a brother, a friend — and one of many affected by improper prescribing practices. Polypharmacy, the prescription of multiple drugs, is a growing problem in the treatment of childhood mental illness. A 2021 study found a near 200% increase in psychotropic, or mind-altering, drug polypharmacy among children 3-18 over the last 20 years. Compounding the issue, pediatric-specific data on the dosing and safety of any of these psychotropic or psychiatric drugs, let alone when taken together, largely doesn’t exist. Clinical testing on children is often deemed too risky, which creates a huge wave of off-label prescribing in which the physician relies on their own judgment to prescribe a drug for a condition rather than hard evidence. 

“It doesn’t mean that any clinical use [in kids] is automatically problematic or invalid,” says Awais Aftab, a psychiatrist based in Ohio. “We just can’t say that we have the same high degree of confidence that we have for ages in which we do have clinical trials.”

One of the few large analyses, a 2016 European review of 34 small trials assessing the effectiveness of antidepressants in children and adolescents found the drugs had no significant benefit over a placebo. Despite this ambiguous efficacy, Prozac, one of the only antidepressants approved by the U.S. Food and Drug Administration for kids 7 and older, is often prescribed for children much younger. In 2014 alone, 83,000 prescriptions for Prozac were written for children under 2 years old, according to data retrieved by the New York Times.

In this extremely young age group, there are no official FDA approvals or guidelines, says Aftab. “It’s kind of like the Wild West in terms of prescribing.”

Is there an age too young to be prescribed a psychiatric drug? The answer, it seems, is no. Sometimes there are justified reasons — but only sometimes, says Julie Zito, a retired professor of pharmacy and psychiatry who has published seminal research on the prevalence of psychiatric medication use in children. For example, she says, some babies are born with chronic, self-injurious conditions. “They might bang their heads against the crib because they don’t know any better,” explains Zito. “In this case, it’s sedation to prevent self-harm.” 

But these well-justified cases don’t include the disproportionate numbers of American preschoolers medicated for normal childhood behaviors. A three-country analysis by Zito found that U.S. children under 4 years old were two to three times more likely to be prescribed psychiatric drugs than Dutch or German children.

“When did we start medicating behavior other than for the severely impaired?” Zito asked. “Imagine a three-year-old who has his whole life ahead of him. You are going to saddle him with medication that may cause adverse outcomes, like excessive weight gain and type 2 diabetes, without sufficient knowledge.” There isn’t adequate public information that the benefits of using these drugs exceed the risks in this age group, Zito adds. 

In the United States, 1 in 11 children under age 18 are on psychiatric drugs, with nearly 110,000 kids under 5 years old prescribed at least one drug. There’s an important caveat, however, for this statistic: the nationwide data don’t indicate the conditions the drugs were prescribed for. For example, children with developmental disorders like cerebral palsy or epilepsy may need these psychotropic drugs as part of their treatment protocols. Still, experts in the field say the drugs are frequently overprescribed.

At a young age, Jena Quinn saw the positive and transformative effect psychoactive drugs had in treating her sister’s epilepsy, which motivated her to pursue pediatric pharmacy as a profession. But the stark reality of childhood prescribing practices shocked her.

As a pediatric pharmacist, Quinn worked tirelessly in hospitals for over a decade correcting children’s medications. Too often, she saw kids on high-risk drugs, prescribed by physicians who didn’t have the formal training to do so. “I was constantly calling their doctor or neurologist saying, ‘Do you know that these two drugs interact? Why would you put this kid on multiple unnecessary drugs that treat the same condition?’” 

But pediatric pharmacists are scarce in numbers, Quinn explains. “There’s only 1,800 of us in the country, so the only time a child would see us is if they were within the hospital’s walls having an acute crisis.”  

Children in the foster system and other settings where access to care is limited are especially vulnerable to unnecessary prescriptions, experts say. A startling 35% of foster kids have been prescribed psychotropic drugs, compared to just 8% of non-foster children, according to a newly published study of over 300,000 children enrolled in Medicaid. 

“Kids in foster care often don’t have access to good insurance, and so psychotherapy is not a realistic option for them,” says Aftab, the Ohio psychiatrist. “This creates a greater reliance on psychiatric medications, and that’s where it gets problematic — it’s a gray area where medication is being used for behavioral control.” 

A class-action lawsuit filed this year against the State of Maryland shows this disparity in real-time: 34% of Maryland foster children are prescribed psychotropic or psychiatric drugs. 

“Most children come into foster care with significant mental health needs,” says Claire Glasspiegel, a senior attorney at Children’s Rights, the New York-based law firm bringing the case. “We want to make sure that those needs are being addressed.” 

The complaint alleges neglectful standards of care for many foster children in Maryland.  A sixteen-year-old Black child in Maryland’s care was prescribed powerful psychotropic medications and suffered severe side effects such as weight gain and trouble controlling his limbs. He ultimately overdosed on his medications while left unsupervised in a motel. After being taken to a hospital for treatment, he was inexplicably placed back into a motel. It was here that he overdosed yet again (and survived, once again).

In all, 72% of Maryland foster children taking these drugs did not have a documented psychiatric diagnosis. This could be due to a dysfunctional medical records system, but Glasspiegel worries that kids are being medicated to avoid costly but more effective approaches like psychotherapy. “We are not trying to remove a useful tool from a medical professional’s toolbox,” she says, but there need to be “checks and balances to [ensure] these medications are truly necessary and helpful.” 

Such an overhaul is possible: by implementing regular checkups and strict prescribing standards, a Texas Medicaid program lowered the share of foster kids given psychotropic drugs by 42% between 2004 and 2019.

With a similar vision, Quinn set up Perfecting Peds as a self-described “quarterback” to holistically assess kids’ medications and negate this polypharmacy nightmare, she says. “People look at me like I’m crazy when I say I’m a pharmacist [who,] most of the time, takes away meds,” Quinn laughs.

In memory of her son, Andrea Sonnenberg and her husband created the Bradley Sonnenberg Wellness Initiative, which offers professional counseling and wellness services for students. The program began at the University of Southern California, where Bradley started his first semester in the theater department. This initiative has inspired others on 60 different campuses across the country through funding raised by Hillel International. “We’re so thrilled to offer this support in Bradley’s name,” his mother says.