In any case, as Congress works on health care legislation that could expand
the nation's Medicaid rolls by 15 million people -- a 43 percent increase -- the scope of the antipsychotics problem, and the expense, could grow in
coming years.

Even though the drugs are typically cheaper than long-term therapy, they are the single biggest drug expenditure for Medicaid, costing the program $7.9 billion in 2006, the most recent year for which the data is available.

The Rutgers-Columbia research, based on millions of Medicaid and private insurance claims, is the most extensive analysis of its type yet on
children's antipsychotic drug use. It examined records for children in seven big states -- including New York, Texas and California -- selected to be representative of the nation's Medicaid population, for the years 2001 and 2004.

The data indicated that more than 4 percent of patients ages 6 to 17 in Medicaid fee-for-service programs received antipsychotic drugs, compared
with less than 1 percent of privately insured children and adolescents. More recent data through 2007 indicates that the disparity has remained, said Stephen Crystal, a Rutgers professor who led the study. 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.

"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."

And yet Dr. Mark Olfson, a psychiatry professor at Columbia and a co-author
of the study, said at least one thing was clear: "A lot of these kids are
not getting other mental health services."

The F.D.A. has approved antipsychotic drugs for children specifically to
treat schizophrenia, autism and bipolar disorder. But they are more
frequently prescribed to children for other, less extreme conditions,
including attention deficit hyperactivity disorder, aggression, persistent defiance or other so-called conduct disorders -- especially when the
children are covered by Medicaid, the new study shows.

Although doctors may legally prescribe the drugs for these "off label" uses, there have been no long-term studies of their effects when used for such conditions.

The Rutgers-Columbia study found that Medicaid children were more likely
than those with private insurance to be given the drugs for off-label uses
like A.D.H.D. and conduct disorders. The privately insured children, in
turn, were more likely than their Medicaid counterparts to receive the drugs for F.D.A.-approved uses like bipolar disorder.

Even if parents enrolled in Medicaid may be reluctant to put their children
on drugs, some come to rely on them as the only thing that helps.

"They say it's impossible to stop now," Evelyn Torres, 48, of the Bronx,
said of her son's use of antipsychotics since he received a diagnosis of bipolar disorder at age 3. Seven years later, the boy is now also afflicted with weight and heart problems. But Ms. Torres credits Medicaid for making
the boy's mental and physical conditions manageable. "They're helping with everything," she said.



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