When federal inspectors set out to examine how powerful antipsychotic drugs were being used on children in the nation’s public health systems, they found a 4-year-old on four psychiatric drugs, a 10-year-old prescribed without medical records, and a 16-year-old on six psych meds, including a prescription at double the maximum recommended dosage.
Poor children and foster kids covered by Medicaid are prescribed too many antipsychotic drugs, too young, for too long, and at the wrong dosages, according to an alarming new five-state review by the U.S. Department of Health and Human Services. The department’s Office of the Inspector General report included California children in its in-depth look at hundreds of medical files and found “quality-of-care concerns” in two-thirds of cases. More than half the children nationwide were poorly monitored, even though the drugs can cause obesity, diabetes and irreversible tremors; more than 40 percent received the “wrong treatment;” and more than one-third simply got “too many drugs,” the report states.
The inspector general’s report — based on Medicaid cases from 2011 in California, Texas, Illinois, Florida and New York — echoed the findings in this newspaper’s ongoing series, “Drugging Our Kids.” The newspaper examined a decade of pharmacy claims for psychiatric drugs prescribed to children in California’s foster care system and found the majority were used to treat difficult behaviors resulting from trauma, not to treat the rare mental disorders such as schizophrenia that the drugs are approved for.
In contrast, the national study included some foster children, but mostly kids living with parents who qualify for public health benefits. It examined a relatively small sample of cases in intense detail, allowing it to draw conclusions about doctors’ practices but not to assess broad patterns and percentages, as the newspaper’s study did.
“It really is a roll of the dice in terms of what we are doing to these kids,” said Chicago psychologist and researcher Robert Foltz, echoing other national experts who reviewed the findings released this week. “The antipsychotics are specifically designed to alter the way we think, feel and behave, and they do that through manipulating the chemicals that are occurring in the brain,” with unknown long-term effects, he added. “We are messing with things we don’t fully understand.”
The extensive use of antipsychotics for behavior management without adequate monitoring is alarming, said Stephen Crystal, a Rutgers University research professor and author of a widely used 16-state study on the use of psychotropics in poor children. The new five-state study, he said, is a loud cry for better oversight.
“The monitoring is not there,” Crystal said. “Somebody writes a prescription, and then they don’t see the kid with sufficient frequency to see how they’re responding to the medication. That’s not good medical practice.”
Crystal also noted the study’s findings could have been even more concerning had its authors weighed each case on whether nondrug therapies were even attempted. “It’s a lot easier to write a prescription than to make sure the kids — in a very timely way — get the services they need,” he said. And few seem to be asking the question: “Is this particular medication making the kids’ behavior worse rather than better?”
Indeed, child and adolescent psychiatrists who reviewed medical records for the inspector general found “a lack of monitoring for many physiological and behavioral changes” in 53 percent of cases. Of particular concern was the failure to perform basic lab tests and regularly monitor height, weight, vital signs, blood pressure and the abnormal, involuntary movements that can result from antipsychotic use.
Only 8 percent of claims examined met the federal standard of “medically accepted,” with many of the drugs prescribed for treatments not approved by the Food and Drug Administration.
Psychiatrists reviewing the case files found numerous medical horrors, including a 10-year-old child diagnosed with attention-deficit disorder who developed a pathological condition from the antipsychotic meds, with increasing dosages that “caused the patient to get worse, not better.” The medical records of a 4-year-old foster child diagnosed with “a mood disorder” and attention-deficit revealed no evidence of any monitoring while four drugs, including two antipsychotics, were being administered — and no evidence that any nondrug treatment or therapies had been attempted. A 16-year-old gained 22 pounds on a total of six psychiatric drugs, couldn’t sleep and suffered from swollen hands and feet. Medical reviewers noted that “when all the medications were discontinued,” there were no further reports of the patient hallucinating or becoming suicidal.
The inspector general focused the study on California and four other large states that represent 39 percent of total Medicaid payments for antipsychotics in 2011, using records for about 485 children. California refers to its Medicaid system as Medi-Cal. Medical files were particularly difficult to obtain in California, where the inspectors received the poorest response rate from health care officials.
The report’s authors call on state and federal health care officials to better track the use of antipsychotics prescribed to children, to ensure there are clear rationales for prescribing and to properly monitor the drugs once prescribed, including adjusting dosages.
But to Bill Grimm, a senior attorney with the National Center for Youth Law who is working with California lawmakers to better protect foster youth from excessive use of psychiatric drugs, the report’s recommendations are far too soft. There are currently no federal Medicaid requirements regarding the appropriate use of antipsychotics prescribed to children, and Grimm is disturbed that abuse of the drugs in nursing homes received far more urgent attention from state and national health care officials.
“The same protections that are afforded seniors against the misuses of these medications,” Grimm said, “should be afforded to our children.”
Contact Karen de Sá at 408-920-5781.
