Therese Mathews has seen the compound fractures abuse and neglect by parents can render to young lives.
The advanced-practice registered nurse has seen many children on numerous medications for behavioral problems in her work at Munroe Meyer Institute in Omaha, she said.
She described the problems in a letter sent in January to the Legislature’s Health and Human Services Committee, which served as testimony on a bill (LB837) that would have created a task force to review state policy on prescription and monitoring of psychotropic drug use by state wards.
The children were prescribed a large number of the drugs for attention deficit hyperactivity disorder, oppositional and disruptive behaviors, autism, anxiety and depression, Mathews said. But many of those medications did not meet standard-of-care guidelines, especially antipsychotics such as Risperdal, Seroquel and Abilify, and mood stabilizers such as Depakote, Lamictal and Trileptal.
"Unfortunately, many of the children have not received or ever been referred for behavioral therapy prior to initiation of an antipsychotic medication," Mathews said.
She noted that a day earlier she saw a 7-year-old boy taking five medications for his behaviors; he was being treated by a primary-care doctor. Among the medications were a mood stabilizer, a hyperactivity drug, an antipsychotic, a stimulant and a seizure medication.
"His behavior was still very disruptive with screaming, head banging and aggression," she said.
In an April memorandum to states from the U.S. Health and Human Services administration of children, families and youth, the federal agency addressed, among other issues, the prescription of antipsychotics for children and youth who had been subjected to mistreatment and trauma and were exposed to violence. According to a 2010 study, children in foster care were prescribed antipsychotic medication at nearly nine times the rate of children enrolled in Medicaid who were not in foster care.
Federal law requires states to submit protocols on overseeing and monitoring the use of psychotropic drugs among children in foster care. The drugs, the federal memo said, should be prescribed with care and justified by clinical evidence, trauma screenings and treatment plans.
Common school-age child and adolescent mental health diagnosis include mood disorders such as depression and bipolar disorder, anxiety disorders such as post traumatic stress and obsessive-compulsive disorder, thought disorders such as schizophrenia, attention deficit and disruptive behavior disorders and others such as separation anxiety, reactive attachment disorder and anorexia.
Nebraska has spent about $38 million in the past three fiscal years on psychotropic drugs for children ages 1 to 18. The amount spent on kids 1 to 5 has gone down from $434,629 to $162,774.
Vivianne Chaumont, Medicaid director with the Nebraska Department of Health and Human Services, said the state's Drug Utilization Review Board -- made up of pharmacists and physicians -- created a preauthorization requirement for doctors prescribing antipsychotic drugs to children younger than 6.
The requirement calls for a Nebraska-licensed child and adolescent psychiatrist, contracting with Medicaid administrator Magellan, to review each case and recommend whether the prescription is necessary and appropriate.
"I think it is a serious issue, and I think we have been doing different things to try to address that issue, but the bottom line is that I think there needs to be a lot more education to physicians about the use of these drugs on kids of all ages," Chaumont said.
Data from Colorado, where she worked before coming to Nebraska, showed family doctors, pediatricians, pathologists and dermatologists prescribed the large majority of these drugs.
“Probably (a) friends of friends type of thing. So that’s a problem,” she said.
Dr. Gregg Wright, director of the Nebraska Department of Health from 1983-91 and now a research associate professor with the Center for Children, Families and the Law at the University of Nebraska-Lincoln, said he believes the preauthorization rule should apply to older children, as well.
It would not be right to say giving psychotropic drugs to kids is never the right thing to do, he said. There are kids who have “very, very serious symptoms.” And the drugs treat symptoms.
“We talk about balancing neurotransmitters, but nobody can measure anybody’s neurotransmitters or know whether they’re balanced,” Wright said. “The real answer is we give them because in other people they have worked. And they can be given safely. I think there are some kids that it might make a very important difference.”
Even drugs that are given “off label,” or used for other treatment than approved by the Federal Drug Administration, can be given with proper monitoring, he said.
Proper monitoring is key. There has been anecdotal information about foster children taking powerful drugs, or multiple antipsychotic drugs, that are not always properly monitored or who experience disruptions in administering the drugs -- especially those children who move from placement to placement.
Wright, who trains child protection and safety workers, tells them having someone ask questions and interact with the doctor produces the best medical care.
“I think kids in foster care are at risk of not having that situation because there’s just so many people involved,” he said. “But certainly the training is pretty strongly oriented toward ‘you really need to deal with these doctors as if it was your own child getting these meds.’”
The 2010 study of 16 states from Rutgers University on antipsychotic medication use in Medicaid children cited five concerns about the use of antipsychotics.
* The possibility that some children may receive care limited to medications without thorough mental health evaluations and other more appropriate services.
* Concerns about the application of diagnostic criteria for bipolar illness and its impact on antipsychotic use in children and adolescents.
* Use patterns that include prescribing multiple psychotropic drugs, administration of appropriate doses and use in children younger than 6.
* Relatively high rates of use not recommended on drug labels, considering the limited knowledge of long-term effects on a child's developing nervous system.
* Strategies to reduce risks related to weight gain and effects associated with some antipsychotics.
LB873 was amended into a bill that created the Children's Commission. The newly appointed group has among its tasks to examine state policy and made recommendations on prescribing and administering psychotropic drugs for state wards.