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Mass. tracks children on psychiatric drugs

Prescriptions eyed after overdose

Four-year-old Rebecca Riley of Hull died of an overdose of psychiatric drugs in December. Four-year-old Rebecca Riley of Hull died of an overdose of psychiatric drugs in December.

Following the death of a 4-year-old Hull girl from an overdose of psychiatric drugs last December, state officials have set up a unique early-warning system to spot preschoolers who may be getting excessive medication for mental illness. In just the first three months, the system has flagged the cases of at least 35 children for further investigation, and the number is sure to rise.

The state Medicaid program is analyzing records of 82,900 children under age 5, looking for those taking at least three psychiatric drugs or a single prescription of a powerful antipsychotic drug. Mental health professionals will review the care of these children and, if necessary, contact the prescribing doctor for an explanation, say officials of the state insurance program for lower-income families, known as MassHealth.

Although cases like the overdose of Rebecca Riley are rare, the prescription of psychiatric drugs to young children is not. Doctors last year prescribed Clonidine - a drug sometimes used to treat hyperactivity that was found in lethal quantities in the Hull girl's bloodstream - to 955 children under age 7 in MassHealth. Doctors also prescribed antipsychotic drugs, which raise the risk of diabetes and obesity, to 536 children under age 7, according to MassHealth records. MassHealth could not say how many of these cases involve children under age 5 and might be subject to review.

Some psychiatrists have been concerned for years about the rise of psychiatric drug treatment of young children, largely because few preschoolers are old enough to show clear signs of mental illness and there are almost no studies on how the chemicals affect their developing brains. But until Riley's death from three drugs she was taking to treat bipolar disorder and hyperactivity, the state provided little oversight of doctors' prescribing practices.

Riley's death "was a wake up call," said Dr. John Straus, vice president for medical affairs at the Massachusetts Behavioral Health Partnership, one of the organizations that manage mental health care for children in MassHealth. He said MassHealth managers want to make sure that doctors have good reason for prescribing psychiatric drugs to such young patients and that they are not relying solely on the parents or guardians for information about each child's condition. Riley's parents have been charged with deliberately giving her a fatal overdose.

"If the behavior is extreme enough to require this level of medication, we ought to make sure that the behavior exists," said Straus, by checking with day-care providers and other independent observers.

The oversight system is too new to say how many cases will merit contacting the prescribing doctor, officials said, but the largest provider of mental health services for MassHealth - Massachusetts Behavioral Health - identified 35 preschoolers in the first three months of the system who were taking three psychiatric medications or one antipsychotic drug. Four other managed-care organizations have also begun reviewing children's MassHealth prescription records, but their findings have not been released.

Nonetheless, Straus said he hopes that fewer than 100 children under age 5 enrolled in MassHealth will trigger the early-warning system in the course of a year.

Deputy Mental Health Commissioner Robert J. Keane, who led the effort to create the tracking system, stressed that it isn't meant to punish doctors or second-guess their judgment. He noted that some children, such as those who are extremely self-destructive, may need multiple medications. However, he said MassHealth's outreach could help some doctors make more informed decisions when they prescribe drugs for very young children.

"Clinical decision making often happens in isolation. It's a problem in healthcare," said Keane, suggesting that some doctors may not realize they are overprescribing psychiatric drugs to preschoolers.

Until the 1990s, children under age 5 were rarely treated with psychiatric drugs for mental illness, in part because the conditions are hard to diagnose in children too young to discuss their feelings or control their impulses. But by 2000, Dr. Joseph T. Coyle of McLean Hospital in Belmont was warning of a "growing crisis in mental health services to children" amid reports that the number of preschoolers taking drugs for attention deficit/hyperactivity disorder had doubled in four years. Writing about a major study of preschool psychiatric drug prescriptions in the Journal of the American Medical Association, Coyle argued that disturbed children were getting drugs as a "quick fix" instead of more time-consuming therapy and other family services.

Riley's death focused attention on the growing use of drugs among preschoolers for another condition, bipolar disorder, which is characterized by wide mood swings and was once thought to begin in late adolescence. Her doctor, Kayoko Kifuji, diagnosed the girl with the condition when she was 2 1/2 years old. Kifuji has voluntarily given up her license to practice medicine while regulators investigate her treatment of Riley, and the girl's mother, Carolyn Riley, said on "60 Minutes" last Sunday that she no longer believes her daughter was bipolar. The parents blame Kifuji for their daughter's death, though she denies wrongdoing.

Despite unease over the amount of psychiatric drugs being prescribed to preschoolers, few states have tried to rein in prescriptions beyond drug educational programs for doctors or other forms of doctor assistance, such as Massachusetts' popular network of psychiatrists who are available for instant phone consultations concerning young patients.

However, one state's experience is instructive: Texas officials adopted an early-warning system last year for mental health care of children in state foster care, and they saw an immediate drop in prescriptions of psychiatric drugs for children under 18 once they started contacting doctors who prescribe large amounts of psychiatric medication. Since 2004, the percentage of foster children receiving at least one psychiatric drug prescription has fallen from 29.9 to 24.4 today.

"Just the fact that doctors are being asked to get involved in this discussion, they are going to be a little more reflective about what they are doing," explained Ted Hughes, spokesman for the Texas Health and Human Services Commission. He added that foster children tend to have a higher rate of medication than others because they often face complex emotional problems.

MassHealth officials said it's unclear whether Massachusetts needs to reduce the rate of drug prescriptions to young children: their records show that the number of young children receiving antipsychotic drugs began declining in 2005.

Keane said that most psychiatric drug prescriptions for preschoolers are written by child psychiatrists rather than pediatricians or family doctors, meaning that trained specialists are making the drug decisions. Riley's doctor was a child psychiatrist at a Boston teaching hospital, Tufts-New England Medical Center.

Under the early-warning system, managed care organizations are reviewing prescription records for all children under age 5 who are receiving mental health treatment paid for by MassHealth. They are expected to keep a closer eye on those who are taking drugs and to conduct a case review of children receiving an unusual quantity or an antipsychotic.

The reviewers will be looking to make sure that the high rate of prescriptions is not an error caused by more than one doctor writing them, and checking to make sure the drugs don't have dangerous side effects when taken together, Straus said. They will also look at the child's history for signs of abuse, evidence of emotional problems, and other issues aside from mental illness that could explain behavior problems. The point is to make sure doctors try other forms of treatment or social services before turning to drugs, Straus said.

Straus said he is encouraged by results of the early-warning system. He said the behavioral health partnership has only contacted a handful of doctors so far to discuss prescriptions for at-risk children, but they had reasonable explanations for the children's treatment plans. "They were being thoughtful about it," he said.

Keane said the new system is an experiment since apparently no other state has done something quite like it before. But, if the tracking system works, he said, it could be expanded to many of the 300,000 Massachusetts children under age 5 who are not in the MassHealth program.

"This is really the start of this process," he said.

Scott Allen can be reached at allen@globe.com.

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