According to research discussed in the New York Times this morning, children whose family poverty makes them eligible for Medicaid are four times as likely to be given antipsychotic drugs than children whose families have private health insurance, and the drugs are more likely to be given to the Medicaid children for less severe mental and behavioral conditions (Wilson,D.[2009, Dec. 12]. Poor children likelier to get antipsychotics. New York Times, p. A1, p. A11). Concerns about this are related to the known potential side effects of such drugs, including serious weight gain and metabolic changes which do not disappear when the medication is stopped. Because of these worries, a group of state Medicaid directors has started a project called "Too Many, Too Much, Too Young" (sorry, I cannot find any web site discussing this project; can readers help?).
Whether the differences in treatment of Medicaid-covered children and privately-insured children are a good thing or a bad one is a question that only appropriate empirical work can answer. It's conceivable, logically, that in spite of the adverse side effects, the "Medicaid children" are receiving benefits that are denied to the privately-insured children. In this post, I am not going to make any attempt to guess at the answer to this question or to recommend how medication OUGHT to be used. Instead, I am going to speculate on possible causes for the situation as it appears to exist. Readers of these speculations should keep in mind two important points: a) that there are differences other than simple income level between the population of families who are eligible for Medicaid and those who are privately insured, and 2) there are treatments for mental illness and behavioral problems that do not involve medication.
So, here are some possible reasons behind the differences in prescription of antipsychotics to different groups of children:
1. Physicians who are paid under Medicaid may feel pressure to examine children quickly and provide quick responses to problems, whereas physicians paid under private insurance plans may feel able to take more time in examining a child and even to delay diagnosis and recommendations.
2. Physicians who are paid under Medicaid and work in clinic settings may have few opportunities (sometimes only one) to see a given child and must make a quick decision about him or her, whereas physicians who are paid privately may have more contacts with the child.
3. A poor family may have been depending on emergency room care and have no experience with a general practitioner who knows the family and can provide a detailed history, whereas private-insurance or private-pay patients are more likely to provide information from a general practitioner who knows the child and the family. Less information about the child may lead a physician to consider worst cases and to recommend powerful medication.
4. Poor families are likely to include adults at a lower educational level than those in privately insured families, and a lower educational level may decrease the adults' willingness or ability to participate in behavioral interventions that can be a useful adjunct to or substitute for medication. Privately insured families are likely to have a higher educational level and therefore more interest in and ability to participate in behavioral or "talking" therapies, which may then be substituted for some or all medication.
5. Families living in poverty and eligible for Medicaid are likely to live in impoverished school districts with relatively little available in the way of child study team support. The parent education approaches that may be found in more affluent districts are thus less available to the poor. Middle-class parents are likely to have a number of sources of helpful parent education programs that can enable them to handle their children more appropriately and reduce the circumstances that exacerbate behavior problems.
6. Families living in poverty are likely to live in neighborhoods with other poor families and to be exposed to experiences that are more frequent in poor neighborhoods. These include domestic and community violence, drug abuse and its related violent events, separation of family members and child placement in foster care or residential treatment. These families are, of course, more likely to be homeless than middle-class families are. Experiences connected with poverty may be direct causes of emotional disturbances such as post-traumatic stress disorders, and they may be indirect ways of triggering behavioral problems in children who are already suffering from anxiety or problems with impulse control. It's possible that conditions related to poverty increase the concerns of families and teachers about children's emotional conditions and long-term prospects, making the adults more likely to ask for prescriptions of antipsychotic drugs for the children.
This list of speculations could easily go on, and no doubt some readers can quickly supply other similar ideas. Those facts tell us something that may be important: there is no single reason for differences between Medicaid and private insurance-supported practices, and there is probably no single outcome we could predict if we were to change the practices dramatically. Instead, we are looking at a situation where complex systemic factors contribute to childhood mental and physical health problems in multiple ways. The possibly inappropriate prescription of antipsychotic drugs for poor children is only one thread in a tapestry of variables that make poverty a threat to child and families.
