Recent news reports in the U.S. have decried the separation of immigrant children from their families seeking asylum and the subsequent use of powerful psychotropic medications without consent. But this egregious offense may be just the tip of the iceberg in terms of overmedicating vulnerable children in the U.S. A recent report by the Office of Inspector General (2018) describes widespread overuse of psychotropic medications with vulnerable children in foster care settings. Further, many of these children did not receive treatment planning or medication monitoring that was required by States, and States did not always require that practitioners follow guidelines from the American Academy of Child and Adolescent Psychiatry.

The following two essays suggest that overuse of psychotropic medications for children in the U.S. is even more widespread. Overuse, or inappropriate use, includes polypharmacy and use of powerful antipsychotic medications for unapproved conditions. Many children are vulnerable. Not only children in foster care but also those with developmental disabilities, those living with families in distress (e.g. families affected by the widespread opioid epidemic), those in the juvenile justice system, those in residential treatment programmes, those who are homeless, those who have psychiatric problems such as depression and suicidality, those who have trauma histories, and many others are at risk for overuse of medications. How many children are vulnerable in these ways is uncertain, but the proportion may be 20% or more (McLaren et al., Reference McLaren, Barnett, Concepcion Zayas, Lichtenstein, Acquilano, Schwartz, Woloshin and Drake2018).

Why are so many children overmedicated? The crux of the matter is this: American culture, including institutions of all kinds, does not protect vulnerable children. The U.S. does not have universal health care, does not support family leave during pregnancy and early childhood, does not have sufficient day care, does not provide equal access to educational opportunities, and does not have accessible, evidence-based, mental health services for children with behavioural difficulties. Thus, children who develop intellectual, emotional, social, learning or behavioural difficulties, unless they have the good fortune of birth to parents with resources, may be considered problems to be controlled rather than fragile human beings worthy of care and protection. While health care and education advocates are relatively weak, the advertising, pharmaceutical, illicit drug, tobacco and unhealthy food industries are powerful and prey on vulnerable children. Moreover, many of these children have no closely involved parents to participate in medical decisions, and many States do not fulfil their oversight responsibilities. In the absence of such protections, the net result is overmedication to control the behaviour of children who have many reasons to manifest difficult behaviours. These vulnerable children need comprehensive care to address the social determinants of poor health as well as comprehensive treatments. Instead, they receive too many medications to control disruptive behaviour and do not receive evidence-based, psychosocial treatments and social services for specific conditions. Tragically, we keep re-discovering that medical solutions for social problems are very expensive and very ineffective.

Used in adults, individual psychotropic medications are often helpful but have significant and sometimes enduring, deleterious side effects, including metabolic, neurologic, physiologic and cognitive problems. For example, adults on antipsychotic medications commonly develop obesity, diabetes and heart disease – serious side effects that are difficult to reverse and decrease longevity. Multiple medications often fail to create synergy but nearly always create additive side effects.

For children, the research and lack of research are more worrisome. Efficacy has usually not been demonstrated: most of the common uses of psychotropic medications in children are not approved by the U.S. Food and Drug Administration. Even more concerning, the potential harms of psychotropic medications in children are legion. The short-term side effects include all of the syndromes seen in adults, often in more severe forms. Children's cerebral, anatomical, physiological, endocrine and other physical features are developing. Similarly, their behaviours, emotions, and social skills and relationships are still evolving with experience. Therefore, the developmental ramifications of overmedication are sometimes dramatic and expansive. For example, an adolescent gaining 40 pounds due to medications suffers psychological, social and emotional distress as well as physiological and endocrine consequences. The long-term effects of most medications on children's metabolism, neurologic function and other systems are largely unknown, because the few existing trials have been short-term studies of one medicine for one specific disorder, not long-term studies of the polypharmacy for mixed conditions that occurs regularly in routine care. Further, the medications are often maintained for months or years without appropriate monitoring of side effects and without government oversight.

The following essays offer constructive directions for children, families, educators, clinicians, policy makers and researchers in the U.S. Each of these stakeholder groups could help. Children and families need better education and greater opportunities to participate in shared decision making. Researchers need to study real-world conditions: complex disorders, multiple interventions and stressful settings. Medical educators need to communicate science in understandable ways. Many well-trained clinicians must provide and advocate for evidence-based practices. State and federal policy makers must avoid industry advertising and fund safe, high-quality care for children. All of us must help to de-stigmatise children who are born or raised in disadvantage. Doing so will require profound changes in managing industry, reducing inequality, protecting family life, improving education, providing high-quality health care to all children and addressing many other aspects of American culture.

Is this situation just an American tragedy? Some European countries do protect families, fund education and social services for all, and prevent the intrusions of industry on health policy more effectively than the U.S. But the abdication of ethical responsibility for disadvantaged children by government in the U.S. should portend danger for other countries. We all share responsibility for vulnerable children who cannot protect themselves.