Recently, The Wall Street Journal broke the story of a federal investigation into the exceptionally high rates of antipsychotic prescriptions for young people in the Medicaid system. According to the article, children who receive care through Medicaid are about four times more likely to be prescribed an antipsychotic than a child on private insurance, and the numbers have tripled in the last decade.
The story raises painful issues about the quality of mental health care given many of our children. These medications can be very helpful -- even life-saving -- for some children, including those for whom they can make the difference between living at home and hospitalization. But the numbers suggest strongly that they are also being improperly prescribed all over the country, as a cure-all for behavior problems.
We worry a great deal about children with psychiatric problems who aren't getting treatment, but we should also worry about those who are getting misguided treatment. It's a particular worry in underserved and vulnerable populations, where there is a shortage of mental health professionals and primary care doctors don't have the time and expertise to do accurate diagnosis.
The reportedly all-too-brief visits to the pediatrician aren't sufficient to diagnose a psychiatric disorder of any kind, or to determine whether a child who is inattentive or disruptive at school has ADHD, is acutely anxious or has been traumatized. The result is often diagnosis-by-prescription: Try the medication, and if the child improves, that must be what was wrong with him. That's definitely not the case.
We've heard from too many pediatricians in disadvantaged neighborhoods that they prescribe stimulant medication because it's the only thing they can do for kids who are struggling in very poorly performing schools and don't have the resources for the kind of behavioral therapy that might give them the tools to turn their lives around. We know the rates of ADHD diagnosis and treatment with medication vary wildly from state to state -- kids are five times as likely to be given ADHD medication in Louisiana, for example, than in Nevada -- and the differences correlate to differences in school policy. The states doing the most prescribing are those that passed early laws threatening a school's funding if it doesn't improve test scores. Medication may seem the quickest way to boost scores, but it won't help kids have better lives unless they really do have ADHD.
But medication mismanagement also occurs because parents are often painfully uninformed about psychiatric problems and how they should expect their kids to be treated. We've seen kids here who are under 7 years old and already on a half-dozen medications: some of them prescribed to counter the side effects of others. The result is a child who is medicated beyond recognition, and we have to get him off all of them and start over before we can even get a good diagnosis.
This is why it's of paramount importance that we arm parents with the information they need to be able to tell if the diagnosis and treatment their children are getting are appropriate. We are frankly dismayed by the stories we hear from parents either coming from unsuccessful treatment or emailing us their questions. We see and hear from way too many whose kids are taking medication that they know very little about, from practitioners who aren't necessarily following best practices.
That's why this spring we developed our Parents Guide to Getting Good Care, to help parents every step of the way from their initial concerns through diagnosis and treatment. For those just starting to explore worries about a child's behavior, our interactive Symptom Checker helps point you in the direction of disorders that might be a good idea to know more about. And our Mental Health Guide, which gives the rundown on 43 psychiatric and learning disorders common in children, has now been updated, to reflect changes in the recently revised diagnostic manual known as the DSM-5.
Parents whose kids are on psychotropic medications need to become informed consumers, able to ask the right questions, sort solid information from hearsay, and recognize red flags when they see them.
We take pride in providing the best of clinical care at our offices -- but we also feel duty-bound to make that standard of care travel as much as possible, especially to underserved or poorly served populations.
Just how outrageous are the roadblocks to children's mental health care? Take the Children's Mental Health Quiz to find out.
Harold S. Koplewicz, MD, is a leading child and adolescent psychiatrist and the president of the Child Mind Institute, whose website, childmind.org, offers information on childhood psychiatric and learning disorders.