By Vera Sharav
Youth and Medicines in June 1-3, 2005
KILEN: Consumers Institute for Medicines and Health
“Forgotten Children” is an investigative report by Carole Keeton Strayhorn, the Texas Comptroller (2004) who uncovered evidence that 60% of children in the Texas foster care system are being drugged with powerful psychotropic drugs, most of which have not been tested in or approved for use by children. The Food and Drug Administration (FDA) acknowledges that many of these drugs have serious adverse side effects, both physical and psychological. The Comptroller said she was alarmed that in her review of a single month (November 2003), two powerful antipsychotic drugs — Risperdal and Zyprexa — made up half of the drugs prescribed to foster children in Texas. These two drugs have been approved only for adults for the treatment of psychosis – primarily schizophrenia – yet, she found that children as young as four, were receiving these powerful, mind-altering drugs.
The number of American children under 19 years of age who are prescribed psychotropic drugs is staggering – the use of these drugs eclipses all other categories for this age group. Between 2000 and 2003, the use of these drugs among teenagers increased threefold, and the number of children treated for “severe behavioral conditions” related to conduct disorder and autism jumped more than 60%. The FDA estimates 11 million antidepressant prescriptions were written in 2003 for under 19 year olds–a 27% increase in 3 years. Drugs used primarily to treat attention deficit/ hyperactivity (ADHD), which remains a controversial “condition,” increased the most. In 5 to 9 year old children the use of drugs increased 85%, and in preschoolers usage was up 49%. Physicians prescribe mind-altering drugs even as they know that for this age group the developing brain is undergoing extraordinary changes. They acknowledge: “we have very little information about the long-term impact of treatment with these drugs early in development.”
The unprecedented number of children being diagnosed with psychiatric conditions, then prescribed psychotropic drugs can be traced to the collaborative efforts of the drug industry and its paid collaborators: professional associations of psychiatrists, leading psychiatrists at prestigious universities, and government health care agencies that are financially dependent on drug companies. Beginning in the 1990s a series of federally sponsored “mental health” initiatives promoted the idea that children’s mental health was in crisis, that they were suffering from undiagnosed depression, and that early treatment is essential to prevent suicide. These influential collaborators flooded the channels of communication with misinformation, persuading doctors and parents that children’s mental health was a major problem and that “safe and effective” remedies were at hand.
Hundreds of news stories including dozens of peer reviewed journal articles repeated the message: the new antidepressants, Prozac and its cousins–sertraline (Zoloft), seroxat (Paxil) – were described as “safe and effective” “magic bullets.” Unlike the old imprecise, sedating antidepressants, these drugs, we were told, are “selective serotonin reuptake inhibitors” (SSRIs) – the implication being that they act with precision on the serotonin receptors. Parents were misled to believe that SSRIs were “safe and effective and well tolerated in children,” when they had shown no benefit greater than placebo, while producing severe adverse effects in children. A mental health epidemic was created (critics believe) to provide an expanded market for new drugs. Even infants and toddlers are prescribed Prozac with the blessing of the medical / psychiatric establishment. In 1998, an FDA contracted survey found that 3,000 Prozac prescriptions had been written for infants.
Of note: Before Prozac antidepressants had been used only for severely depressed, hospitalized patients who were at high risk of suicide. The advent of Prozac changed all that – anyone expressing a sign of unhappiness, anxiety, or moodiness from the ebb and flow of life, was diagnosed as suffering from depression. When tested in controlled trials, the new generation antidepressants have failed to demonstrate a benefit either for severely depressed hospitalized patients or for troubled children. The business success of Prozac is attributable to creative aggressive marketing. However, the new antidepressants – SSRIs and SNRIs (selective serotonin norepinephrine reuptake inhibitors)–pose significant life-threatening risks of harm which, for almost two decades, had been concealed from the public. The most serious documented harm links SSRIs /SNRIs to increased risk of suicide and violence in youth.
Prescribing physicians in Europe and the US were kept in the dark about the serious risks until paroxetine (Paxil) was exposed by the BBC (2003). The drug was shown to cause severe withdrawal symptoms – a sign of drug dependency – and it triggered violent outbursts and suicide. The UK medicines authority (MHRA) was first to issue a public warning about the dangers of Paxil in June 2003, and to ban the use of SSRIs / SNRIs in children, save Prozac. In March 2004, the US FDA followed, issuing extensive bold warnings about the increased risk of suicidal behavior in both children and adults who take an antidepressant – for any condition “psychiatric or non-psychiatric.” In October 2004, the FDA issued black box warnings about the twofold increased risks of suicidal behavior in youth taking any antidepressant, including Prozac.
The European Medicines Agency (EMA)  is the last regulatory agency to catch up. In April (2005), the EMA’s scientific committee (CMHU) issued a press release recommending warnings on the labels of all the new SSRI / SNRI antidepressants to reflect the evidence: “SSRIs/SNRIs should not be used in the treatment of children and adolescents unless specifically authorised. Suicide-related behaviours (suicide attempt and suicidal thoughts), and hostility (predominantly aggression, oppositional behaviour and anger) were more frequently observed in clinical trials among children and adolescents treated with antidepressants compared to those treated with placebo.” The EMA added Strattera (atomoxetine) to the list of drugs prescribed for children, noting its “lack of efficacy in depression.” Strattera is approved only for the treatment of ADHD for adults and children: but it poses increased risks which constitute the very symptoms that constitute a diagnosis of ADHD: “hostility, aggression, oppositional behavior, and anger.”
Antipsychotics are the most powerful, most toxic psychotropic drugs that have neither been tested in, nor approved for use by children, yet they are the second most widely prescribed drugs for children. Although the scientific evidence for their effectiveness is tenuous, nevertheless, these powerful drugs are widely prescribed primarily for off-label uses. Antipsychotics were approved for the treatment of psychosis in adults, primarily for schizophrenia and short-term use for bipolar disorder. These drugs induce severe, potentially fatal adverse effects and now carry FDA required warnings that they impair judgment, thinking, and motor skills. Since 2003 the labels carry black box warnings about potentially fatal diabetes mellitus, especially in youth. They also carry risks of prolonged heart QT interval, cardiac arrhythmia and stroke. Antipsychotics are the fourth highest selling class of prescribed drugs in the US– sales in 2002 reached $6.4 billion.2 The greatest spending increase for the treatment of children diagnosed with behavior problems, is due to skyrocketing use of the most expensive drugs to treat ADHD, conduct disorder, autism, and affective disorders such as depression.
These drugs are known to induce severe, potentially fatal adverse effects and now carry FDA required warnings about the risks of cardiac arrhythmias, impaired judgment, thinking, and motor skills. Since 2003 the labels carry black box warnings about potentially fatal diabetes mellitus, especially in youth. Concerns are being raised about why young people who are not psychotic are being prescribed these powerful drugs for unapproved uses without evidence of their safety.
Investigations across the US corroborate the abusive use of psychotropic drugs:
- The Massachusetts Behavioral Health Partnership reported that almost two thirds of children in state care were treated for behavioral disorders in 2003.
- An analysis of the medical records of 300,000 children aged 2 through 18 who were enrolled in the Tennessee Medicaid healthcare program for the poor and uninsured found that the use of antipsychotics for children nearly doubled in six years. Nearly one in every 100 adolescents covered under the Tennessee program was being prescribed antipsychotics in 2001. The increases were most dramatic among children aged 6 to 12 (a 93% rise) and those aged 13 to 18 (a 116% increase). The use of antipsychotics among preschool children increased 61%.
- An investigative series in Columbus Ohio found that 40,000 children aged 6-18 who were covered by Medicaid were prescribed psychotropic drugs: 31% of those children were in foster care, and 22% were in juvenile detention. Medicaid spent $65.5 million for drugs used primarily as “chemical restraints.” Among these:
- Chelsey Kennedy, 15, says she “slept for four days and was in a drug-induced fog for a week” after being subdued with three shots of a powerful drug at a Dayton treatment center. Now she’s at a Columbus center, but her mother worries about the number of medications she takes daily – 14, of which 11 are psychotropic drugs, compared with two when she went into treatment two years ago.
- A 10-year-old boy was chemically restrained 69 times over 80 days. Doctors prescribed up to six drugs at a time – no one has ever determined which pills worked for what symptoms or disorders.
- A 12-year-old girl was injected six times over nine months with high doses of Thorazine, a powerful sedative that can knock kids out and cause painful muscle spasms and twitches. She also was physically restrained 31 times by as many as three men, despite a history of being physically and sexually abused.
- A Texas mother reported that starting at age five her son was variously diagnosed as suffering from ADHD, bipolar disorder, schizophrenia, or sociopathy – diagnosis depended on the doctor in charge. The boy was put on powerful psychotropic drugs which, she says, made him hear voices, and resulted in troubles in school, with the law, and repeated hospitalizations. When he was put on Zyprexa “he put on a tremendous amount of weight, 85 pounds to be exact.” Since being weaned off the drugs, she reported that her son is much improved.
- A five month investigation by the Tampa Florida Tribune shows how misprescribing psychiatric drugs can precipitate life-threatening tragedies. For example, 9- year old Lee who had been diagnosed with bipolar disorder descended into suicidal violence after she had been haphazardly prescribed a combination of four powerful drugs – two antidepressants and two antipsychotics. She developed an obsessive fear of germs, for which the psychiatrist suggested an antidepressant (Paxil). Within weeks, Lee’s mother noticed a surge in her aggression. She told the doctor, but he said it was an acceptable side effect and she would be fine. Well, she was not fine: “Emergency workers cornered her behind the office and tied her to a gurney. She screamed and thrashed the whole way to the Community Hospital emergency room and screamed throughout the afternoon as nurses tried to sedate her. They finally succeeded by giving her a shot of Thorazine.”
How can such abuse possibly be therapeutic for any 9 year old child?
- A series in the California Sacramento Bee described what happened to 12-year old Zach during a period of 18 months. Zach was diagnosed with anxiety, depression and ADHD: he was first prescribed Ritalin, then Prozac, then paroxetine (Paxil) which made him manic. Then, he was back to Prozac plus the antipsychotic, Zyprexa, which made him gain 40 lbs within 5 months. He was then prescribed quitiapine (Seroquel), the dose was raised but his psychiatrist said he is “disappointed” because Zach is still irritable, so he’s considering the newest antipsychotic, ziprasidone (Geodon). The drug label carries bold warnings about rapid heart beats and cardiac arrest: “sudden unexplained deaths have been reported in patients taking ziprasidone at recommended doses.”
- A Dallas Fort Worth investigation found that in one month (November 2003), some doctors were writing as many as 486 prescriptions for psychotropic drugs for children in foster care. One psychiatrist explained to the reporter in an e-mail: “I am often pressured by providers to aggressively medicate children in an attempt to control their behavior.”
Dr. Ellen Bassuk, professor at Harvard University who examined children’s medical records said: “It’s scandalous that medications are used to subdue kids for the convenience of overworked and underpaid staff or as punishment for bad behavior.” The Texas comptroller agrees: she believes the drugs are prescribed for children in order to make them “more docile.” And, she deplores that “doctors and drug companies are pushing them to make a buck.” And a neuropsychologist from Florida who examined the Texas records said that by numbing children with psychotropic drugs:
“We’re taking away their future.” By blunting their emotion, we take away children’s ability to relate to people, to trust, love, to care for others or to put themselves in another person’s shoes to see how it feels.
To make matters even worse, the US government has begun to implement a mental health screening policy recommended by the President’s New Freedom Commission on Mental Health (NFC). According to the BMJ, President Bush instructed more than 25 federal agencies to develop an implementation plan to screen America’s 52 million school children and 6 million school personnel – for hidden mental illness. The rationale behind this mind-boggling initiative is, in part, evidence of America’s abiding faith in science and technology to provide solutions for complex human and societal problems. In no other democratic country has the government adopted a policy to screen the entire population – children first – for presumed, undetected, mental illness.
The methodology used to screen for mental and behavioral problems remains rooted in the flawed methods used by the discredited eugenics movement which sought to screen for mental “defectives.” Eugenics and psychiatry suffer from a common philosophical fallacy that undermines the validity of their theories and their prescriptions. Both are rooted in “faith-based” ideological assumptions that mental and behavior problems are biologically determined, and can, therefore, be resolved through biological interventions.
However, the diagnosis of mental illness lacks scientific validity – it relies entirely on the subjective assessment by mental health professionals and normative check lists. This flaw was acknowledged by the US Surgeon General report: “mental health is not easy to define·.what it means to be mentally healthy is subject to many different interpretations that are rooted in value judgments that may vary across cultures.” Another shortcoming: mental health professionals have an interest in expanding the patient roster to guarantee their employment. Therefore, screening will most likely inflate the number of American children (and adults) labeled with a mental illness.
The New Freedom Commission Report praised two mental health programs: TeenScreen and TMAP. TeenScreen is a questionnaire devised by psychiatrists at Columbia University “to ensure that every teen in the US has access to free mental health check-up.” TeenScreen is already operating in more than 100 schools in 34 states and as the executive director told a congressional committee: “In 2003, we were able to screen approximately 14,200 teens…; among those students, we were able to identify approximately 3,500 youth with mental health problems and link them with treatment. This year, we believe we will be able to identify close to 10,000 teens in need, a 300 percent increase over last year.” Unfortunately this is not science fiction: this is a policy driven by commercial interests.
TMAP (Texas Medication Algorithm Project) is an industry sponsored set of flow charts designed to guide mental health providers’ selection of psychotropic drugs– “Psychiatry for Dummies.” TMAP was launched in 1995, when Bush was governor of Texas. TMAP recommends the most expensive drugs as first line treatment – these are the SSRI and SSNRI antidepressants and antipsychotics. At least twelve states have adopted the TMAP model: Texas and Ohio were among the first. State mental health officials across the US see nothing wrong with prescribing drugs irresponsibly, thereby violating medicine’s first principle–“do no harm” – to increase profits. Of note, Ohio’s executive director of the Department of Mental Health, Michael Hogan, who has played a major role in promoting the use of psychotropic drugs, was chairman of the New Freedom Commission. He said that although: “It’s true children are more likely to get medication than counseling or other behavioral therapy, at the end of the day, meds re quite safe and effective.”14 Hogan says the biggest danger facing children is depression.
Screening for mental illness serves no medical purpose – it is but the first step toward expanded use of drugs. Given its large margin of error, screening for mental illness is of dubious value for individuals, but that same margin of error is of great value for the drug industry. An evaluation by the authoritative US Preventive Services Task Force concluded that the mental health screening instruments have not been validated, and there is no evidence to demonstrate that screening reduces suicide. The escalating expenditure for psychotropic drugs since TMAP leaves little doubt as to its value for the drug industry. The impact of TMAP is already evident in the skyrocketing increased prescriptions for antipsychotics which are being prescribed widely for unapproved, off-label uses, mostly to control conduct and behavior, including ADHD. US spending for drugs to treat ADHD rose astronomically3: among 5 to 9 year olds spending rose 174%, and for preschool children spending rose by 369%. These extraordinary spending increases reflect the increased use of the most expensive drugs to treat newly minted behavioral problems in children who are increasingly diagnosed with ADHD and bipolar disorder (a.k.a. manic-depression).
Indeed, the Wall Street Journal reported last week: “The number of children diagnosed as bipolar rose 26% from 2002 to 2004, to 19,776 cases,” noting that until recently, children under 18 were very rarely diagnosed with bipolar disorder. Yet, today, children as young as four are being diagnosed with bipolar. The Journal also notes that: “increased use of antipsychotic medicines, such as Seroquel and Risperdal, was a big driver of pediatric drug costs last year.” Indeed, overall spending on psychotropic drugs for children increased by 77%, and increased by 142% for “severe conduct disorder.”
Screening will do much to expand the number of patients relegated to mental health providers and to increase profit margins for drug manufacturers. In the last two years, 107,000 children in Texas have been prescribed psychotropic drugs at a cost of $167 million. The experience of 15-year old Aliah Gleason, encapsulates the abuse a child is likely to be subjected to after being screened and (often as not) misdiagnosed as having a mental disorder. Her story is reported in Mother Jones. 
MEDICATING ALIAH (excerpt)
In the early part of seventh grade, Aliah was a B and C student who got in trouble “for running my mouth.” School officials considered Aliah disruptive, deemed her to have an “oppositional disorder,” and placed her in a special education track. Her parents viewed her as a spirited child who was bright but had a tendency to argue and clown. Then one day, psychologists from the University of Texas (UT) visited the school to conduct a mental health screening for sixth- and seventh-grade girls, and Aliah’s life took a dramatic turn.
A few weeks later, the Gleasons got a “Dear parents” form letter from the head of the screening program. “You will be glad to know your daughter did not report experiencing a significant level of distress,” it said. Not long after, they got a very different phone call from a UT psychologist, who told them Aliah had scored high on a suicide rating and needed further evaluation. The Gleasons reluctantly agreed to have Aliah see a UT consulting psychiatrist. She concluded that Aliah was suicidal but did not hospitalize her, referring her instead to an emergency clinic for further evaluation. Six weeks later, in January 2004, a child-protection worker went to Aliah’s school, interviewed her, then summoned her father to the school and told him to take Aliah to Austin State Hospital, a state mental facility. He refused, and after a heated conversation, Aliah was placed in emergency custody and a police officer drove her to the hospital.
The Gleasons would not be allowed to see or even speak to their daughter for the next five months. Aliah would spend a total of nine months in a state psychiatric hospital and residential treatment facilities. While in the hospital, she was placed in restraints more than 26 times and medicated-against her will and without her parents’ consent-with at least 12 different psychiatric drugs, many of them simultaneously.
On her second day at the state hospital, Aliah says she was told to take a pill to “help my mood swings.” She refused and hid under her bed. She says staff members pulled her out by her legs, then told her if she took her medication, she’d be able to go home sooner. She took it. On another occasion, she “cheeked” a pill and later tossed it into the garbage. She says that after staff members found it, five of them came to her room, one holding a needle. “I started struggling, and they held my head down and shot me in the butt,” she says. “Then they left and I lay in my bed crying.”
What, if anything, was wrong with Aliah remains cloudy. Court documents and medical records indicate that she would say she was suicidal or that her father beat her, and then she would recant. (Her attorney attributes such statements to the high dosages of psychotropic drugs she was forcibly put on.) Her clinical diagnosis was just as changeable. During two months at Austin State Hospital, Aliah was diagnosed with “depressive disorder not otherwise specified,” “mood disorder not otherwise specified with psychotic features,” and “major depression with psychotic features.”
In addition to the antidepressants Zoloft, Celexa, Lexapro, and Desyrel, as well as Ativan, an antianxiety drug, Aliah was given two newer drugs known as “atypical antipsychotics”–Geodon and Abilify–plus an older antipsychotic, Haldol. She was also given the anticonvulsants Trileptal and Depakote-though she was not suffering from a seizure disorder-and Cogentin, an anti-Parkinson’s drug also used to control the side effects of antipsychotic drugs. At the time of her transfer to a residential facility, she was on five different medications, and once there, she was put on still another atypical-Risperdal.
At times Aliah “was on five different medications, putting her on the extreme end of a growing practice known as polypharmacy that worries many doctors.” Dr. Joseph Woolston, a Yale University professor and chief of child psychiatry at Yale said: “If you or I were on that regimen we would have a lot of trouble attending to work or school. We don’t have any idea what that combination of medications does to a developing child. It may have a number of long-term side effects.” He also suspects “that the drugs may have been used as much to control the angry reactions of a girl who was hospitalized against her will as to treat any mental and emotional problems.”
Aliah was a victim of mental health screening. Screening for mental illness serves no medical or societal purpose – screening will, however, do much to increase the profit margins for drug manufacturers and the mental health provider industry. A label of mental illness all too often signifies loss of autonomous decision-making authority for parents who may be reluctant to give permission for their children to be treated with psychotropic drugs.
A dark side of screening is the stigma that accompanies those labeled as having a mental disorder. Being so classified all too often signifies loss of autonomy and decision-making authority. Parents who are reluctant to give permission for their children to be treated with psychotropic drugs – such as Aliah Gleason’s parents – face state agents who impose their authority over parental objections. American psychiatry is treading down the same slippery slope that the eugenics movement did in its heyday. Psychiatry, like eugenics, is armed with an arsenal of unproven bio-genetic theories and assumptions about human behavior. Eugenicists blamed heredity for bad behavior: psychiatrists blame unproven faulty brain chemistry. Eugenics imposed radical interventions against the will of the individuals targeted – so does psychiatry.
Eugenicists and psychiatrists have done incalculable harm because their “treatments” were sanctioned by a government seal providing the illusion of legitimacy. In the US, state Eugenics boards approved the involuntary sterilization of 72,600 people who had been classified (often arbitrarily) as “mental defectives.” Psychiatry uses state agents to coerce parents to force children to ingest drugs that disrupt normal brain function.
Who will bear responsibility for the harms that may follow from mental health screening when children are wrongly labeled as having a mental illness, and on that basis will be prescribed mind-altering drugs that cause them harm?
Who will compensate children who will be deprived of a normal childhood?
 Strayhorn, CK. Forgotten children, Texas Comptroller, April 2004. http://www.window.state.tx.us/forgottenchildren/execsumm/
 Freudenheim M. Behavior Drugs Lead in Sales for Children, New York Times, May 17, 2004. http://www.nytimes.com/2004/05/17/business/17drug.html?ex=1085815432&ei=1&en=72cd66cf54ffd8d4
 Medco Health Solutions, Inc. 2004 Drug Trend Symposium. Study Reveals Pediatric Spending Spike on Drugs to Treat Behavioral Problems, May 17, 2004. http://biz.yahoo.com/prnews/040517/nym080_1.html
 Coyle, J. (2000). Psychoactive drug use in very young children. Editorial. Journal of the American Medical Association, 283. Retrieved February 23, 2000 from http://jama.ama-assn.org/issues/v283n8/ffull/jed90109.html
 See: Sharav, VHS. Children in clinical research: A conflict of moral values. American Journal of Bioethics. (2003) 3(1): InFocus online at: http://s97929468.onlinehome.us/journal/pdf/3_1_IF_w12_Sharav.pdf; U.S. Surgeon General Report. Conference on children’s mental health: A National Action Agenda. January 3, 2001. Online (accessed Oct 2, 2004) at: http%3A%2F%2Fwww.surgeongeneral.gov%2Ftopics%2Fcmh%2Fdefault.htm
 Wagner KD, Ambrosini P, Rynn M, et al: Efficacy of sertraline int eh treatment of children and adolescents with Major Depressive Disorder. JAMA 2003; 290(8):1033-1041. See also: Emslie GJ, Rush AJ, Weinberg WA, et al (1997b). A double-blind, randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression. Arch Gen Psychiatry 54:1031-7; Keller, MB, Ryan ND, Stober M, et al.: Efficacy of paroxetine in the treatment of adolescent major depression: a randomized, controlled trial. J AM Acad Child Adolesc Psychiatry 2001; 40(7):762-772.
 Grinfeld, M. 1998. Psychoactive medications and kids: New initiatives launched. Psychiatric Times. Vol 14 (3) March: p. 69.
 See UK letter to healthcare providers (June 18, 20030): https://ahrp.org/risks/PaxilRisks0603.php; UK MHRA bans use of SSRI antidepressants in children (December 10, 2003): https://ahrp.org/infomail/03/12/15.php
 FDA Advisory warning: Antidepressant Use in Children, Adolescents and Adults: http://www.fda.gov/cder/drug/antidepressants/default.htm
 FDA. Antidepressant ‘Black Box’ label warning http://www.fda.gov/cder/drug/antidepressants/SSRIlabelChange.htm
 The drugs listed: citalopram, escitalopram, fluoxetine, fluvoxamine, mianserine, milnacipran, mirtazapine, paroxetine, reboxetine, sertraline and venlafaxine and atomoxetine.
See: European Medicines Agency. Committee on Medicines for Human Use (CMHU). European Medicines Agency finalises review of antidepressants in children and adolescents http://www.emea.eu.int/pdfs/human/press/pr/12891805en.pdf
 Vascellaro JE. Prevalence of drugs for DSS wards questioned, THE BOSTON GLOBE, August 9, 2004. http://www.boston.com/news/local/articles/2004/08/09/prevalence_of_drugs_for_dss_wards_questioned?mode=PF
 Gardner, A. Use of Antipsychotics Doubles for Low-Income Kids Tennessee study suggests treatment decisions are behind trend. HealthDay, August 4, 2004. http://www.healthday.com/view.cfm?id=520474
 Pyle, P. Drugged into Submission: Forced medication straitjackets kids. Series. Columbus Dispatch, April 24, 2005, http://www.dispatch.com/reports-story.php?story=dispatch/2005/04/24/20050424-A1-00.html
 Hughes, PR. Strayhorn will probe drug use on children Comptroller asks for medical data on children in foster care. Houston Chronicle Austin Bureau Nov. 12, 2004.
 Dorsey Griffith. Walking a medical tightrope: With few drugs tested for children, physicians rely on trial and error. Sacramento Bee, June 24, 2002, Second of three parts. http://www.sacbee.com/content/news/projects/medication/story/3328394p-4356008c.html
 Koffer S. Investigation into foster care doctor recommended, WFAA, October 4, 2004, http://www.wfaa.com/sharedcontent/dws/wfaa/localnews/news8/stories/wfaa041003_am_fosterdoc.36e7d808.html
 Neuropsychologist, Dr. Tony Appel quoted in: Garrett, R. Drug fraud alleged in foster care, The Dallas Morning News. November 12, 2004.
 President’s New Freedom Commission on Mental Health. Final Report. April 3, 2003. http://www.mentalhealthcommission.gov/reports/reports.htm; President’s New Freedom Initiative for People with Disabilities: The 2004 Progress Report. www.whitehouse.gov/infocus/newfreedom/toc-2004.html
 Lenzer J. Bush Plans to screen whole US population for mental illness. British Medical Journal. June 19, 2004, 328: 1458 http://bmj.bmjjournals.com/cgi/content/full/328/7454/1458
 U.S. Surgeon General Report on Mental Health. 1999. p.5 http://www.surgeongeneral.gov/library/mentalhealth/pdfs/c1.pdf
 U.S. Preventive Services Task Force. Screening for Suicide Risk: Recommendation and Rationale. May 2004. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/suicide/suiciderr.htm
 Aboud, L. Treating Children for Bipolar Disorder: Doctors Try Powerful Drugs On Kids as Young as Age 4, Wall Street Journal, May 25, 2005, p. D-1.
 Sharav VH. Screening for Mental Illness: the Merger of Eugenics and the Drug Industry Presented at the International Center for Psychiatry & Psychology, October 8, 2004. In Press. Ethical Human Services & Sciences, 2005.