Note the first two paragraphs of a rather alarming story in the New York Times from Saturday which suggests we are, once again, failing our most vulnerable and poor children:
Poor Children Likelier to Get Antipsychotics
New federally financed drug research reveals a stark disparity: children covered by Medicaid are given powerful antipsychotic medicines at a rate four times higher than children whose parents have private insurance. And the Medicaid children are more likely to receive the drugs for less severe conditions than their middle-class counterparts, the data shows.
Those findings, by a team from Rutgers and Columbia, are almost certain to add fuel to a long-running debate. Do too many children from poor families receive powerful psychiatric drugs not because they actually need them — but because it is deemed the most efficient and cost-effective way to control problems that may be handled much differently for middle-class children?
Notice that it is only in paragraph 21 that mention is made that the Medicaid population has certain attributes that may confound the import of the headline:
Experts generally agree that some characteristics of the Medicaid population may contribute to psychological problems or psychiatric disorders. They include the stresses of poverty, single-parent homes, poorer schools, lack of access to preventive care and the fact that the Medicaid rolls include many adults who are themselves mentally ill.
As a result, studies have found that children in low-income families may have a higher rate of mental health problems — perhaps two to one — compared with children in better-off families. But that still does not explain the four-to-one disparity in prescribing antipsychotics.
Professor Crystal, who is the director of the Center for Pharmacotherapy at Rutgers, says his team’s data also indicates that poorer children are more likely to receive antipsychotics for less serious conditions than would typically prompt a prescription for a middle-class child.
But Professor Crystal said he did not have clear evidence to form an opinion on whether or not children on Medicaid were being overtreated.
And it is only paragraph 25 that makes explicit, though in an understated way, that the overt behavior of "Medicaid kids" makes the initial headline impossible to evaluate.
“Medicaid kids are subject to a lot of stresses that lead to behavior issues which can be hard to distinguish from more serious psychiatric conditions,” he said. “It’s very hard to pin down.”
The aforementioned paragraph does not do justice to the problems of the "Medicaid kids". I have always split my time between private practice and clinic practice working with the financially less fortunate. In the first clinic at which I worked I saw children for evaluations and, on several occasions, for treatment. I did not prescribe medicine in the vast majority of cases. I do not like the idea of bathing a developing brain in psychoactive chemicals unless the indications are overwhelming. In any case I found that while I could offer the children therapy and gain their parents' acquiescence to the treatment plan, I could never obtain much long term compliance, even (maybe especially) when the children responded well to the treatment. Either the parent (and the majority were living in one parent homes, the product of relationships that were never formalized by the state) missed too many appointments because of competing needs/desires, or they suddenly disappeared from the clinic (sometimes because they moved with no warning to therapist or child.) On other occasions one parent would use attendance by the child as a club with which to attack the other, ie in one case, the father wanted the child in therapy (and the actual involvement of the father was the exception rather than the rule) while the mother, realizing she could hurt the father, refused to allow the treatment to continue even after the school told the mother her son was improving. After enough of these failed attempts, I essentially gave up; it was too distressing to see so many children suffering because of their parents' pathology. It is difficult to become attached to a child, even if only therapeutically, and to see the child becomes attached and involved in their therapy, and then have the child taken out of therapy despite its manifest benefits.
[It is certainly possible that I was handicapped by my inexperience, my lack of cultural and ethnic similarity, or some other combination of factors that rendered me a particularly poor fit for these children or, I might just have been a terrible therapist. Yet, I never had similar problems with White or Oriental children. (The children it the clinic were predominantly Black and Hispanic {Mexican}). Nor did I have trouble treating adult minorities; my patients tended to have better than average outcomes for the clinic. Finally, even if I was a poor child therapist with all sorts of limitations, the question must arise as to why it should be that one set of children are able to gain benefits even from a sub-optimal therapist, while another set of children could not.]
By the time I began to work in the second clinic I joined, I decided not to treat children there. In this clinic, too, far too many of the "Medicaid kids" were referred to the clinic because their behavior was so out of control (in school primarily) that they were disruptive to others and impossible to teach. It was quite literally impossible to tell with many of these youngsters if their behavior reflected an internally disordered Central Nervous System or was a reflection of a CNS that could function adequately in a better environment. In other words, the chaos at home was being put into action by the child. Most of these "Medicaid kids" were given Medicine to treat problems whose source lay in the home environment. In addition, far too many had trouble keeping appointments because the parents' pathology interfered.
This kind of news story, and I do not believe that there is any conscious intent to distort or obfuscate the news, is the kind of story that has traditionally led to disastrous social interventions. For example, it was found quite some time ago that minority children, especially poor minority children, had disciplinary problems and were suspended and expelled at far higher rates than White or Oriental children. Lawyers and Judges decided the disparity was evidence of bias and rules were established that made it extremely difficult to remove disruptive children form the classroom. As a result, actual teaching became a secondary exercise, children who might have been educated went through school with their self esteem artificially enhanced while their 3 R's were nearly non-existent, and the urban schools became places for intact, achieving parents to eschew for their children.
If that pattern is repeated, we will soon have mandates that minimize our ability to treat disruptive and disturbed children (and admittedly, the treatment options are suboptimal and the most useful treatments, ie changing their home environment, near impossible to achieve) , there will be more children disrupting mainstream classrooms, more children forced into Special Ed classrooms, and fewer children actually available for learning in our schools; all with the best of intentions, to protect poor children.
The current administration could begin to address the problem of failing minority families that are leaving us with such difficult trade-offs, but that would require a conversation that our courageous Attorney General and President have thus far avoided.
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