Psychotropic Medication in Foster Care...in foster care is to be provided to group home...
Transcript of Psychotropic Medication in Foster Care...in foster care is to be provided to group home...
Version1.0|2017
PsychotropicMedicationinFosterCare
TraineeGuide
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 2
TableofContents:Background and Context ................................................................................................. 3Curriculum Introduction ................................................................................................... 6Agenda ............................................................................................................................ 7Learning Objectives ......................................................................................................... 8Segment 1: Welcome and Introductions ......................................................................... 9Segment 2: Laws and Regulations ................................................................................ 10Segment 3: Court Process and Forms .......................................................................... 13Segment 4: Trauma ....................................................................................................... 15Segment 5: Accessing Services .................................................................................... 20Segment 6: Psychotropic Medication ............................................................................ 27Segment 7: Using the California Guidelines .................................................................. 38Segment 8: Wrap Up and Evaluation ............................................................................ 43Resources ..................................................................................................................... 44References .................................................................................................................... 45
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 3
BackgroundandContextTheuseofpsychotropicmedicationamongchildrenandyouthintheUnitedStateshasincreasedsignificantlyoverthelasttwodecades,particularlyforchildrenandyouthinfostercare(Longhofer,Floersch,&Okpych,2011;Raghavan,Lama,Kohl,&Hamilton,2010).Raghavanandcolleagues(2005)estimatethat13%ofallchildrenandyouthinthechildwelfaresystemnationwidereceivepsychotropicmedicationscomparedto4%ofchildrenandyouthinthegeneralpopulation.In2014theSanJoseMercuryNewsfoundthatfrom2004to2014,nearly1outof4adolescentsintheCaliforniafostercaresystemreceivedpsychotropicmedications—3.5timestherateforalladolescentsnationwide.Ofchildrenandyouthincarewhowereprescribedpsychotropicmedications,60%receivedthestrongestclass—antipsychotics.Whatisparticularlyconcerningistheprescriptionofmultiplemedications(i.e.,polypharmacy).Thenewspaperstudyalsofoundthatin2013,12.2%ofchildrenandyouthincarewhowereprescribedmedicationswereprescribedmorethanonemedicationatatime.
Mackieandcolleagues(2011)listanumberoffactors,whichmayormaynotberelatedtoclinicalneed,thatexplainwhythispopulationofchildrenandyoutharedisproportionatelyprescribedpsychotropicmedications,including:higherratesoftraumavictimizationandmentalhealthdisordersfoundinthispopulation;traumacausedbybeingremovedfromfamilyoforiginandmultipleplacementchangesthereafter;andthecomplexemotionalandbehavioralsymptomsthataccompanyalltheseunderlyingcircumstances;lackofclearoversightandmonitoringguidelinesandprotocols;anincreaseinmedicationprescriptionsinoutpatientsettings;andinadequateaccesstoMedicaidservices.
Researchrepeatedlyfindsthatchildrenandyouthinthefostercaresystemarediagnosedwithmentalhealthdisordersmoreoftenthanchildrennotinfostercareandarethereforemorelikelytobeprescribedpsychotropicmedications(Longhofer,Floersch,&Okpych,2011;Sheldon,Berwick,&Hyde,2011).Themostcommondiagnosesamongchildrenandyouthinfostercareareconductdisorder/oppositionaldefiantdisorder,depression,attentiondeficit/hyperactivitydisorder,andposttraumaticstressdisorder.Commonlyprescribedmedicationsforchildrenandyouthinfostercareincludeantipsychoticstotreatschizophrenia,bipolardisorder,andautismwithirritability;stimulantsto
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 4
treatsymptomsofattentiondeficithyperactivitydisorder;antidepressantstotreatmajordepressionandobsessivecompulsivedisorder;andmoodstabilizersforaggressivebehaviorandunspecifiedemotionalproblems.
Inresponsetothisdata,Californiahastakenstepstobuilduponpreviouslegislationandexpandanddevelopnewguidelinesthatcontinuetopromotethebasicprinciplesofsafety,permanency,andwellbeing,withtheaddedgoalofreducingshort-andlong-termharmcausedbyinappropriateprescriptionsanduseofpsychotropicmedications.AspartoftheFosterCareQualityImprovementProject,TheCaliforniaDepartmentofHealthCareServices(DHCS)andtheCDSSreleasedtheCaliforniaGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCare,2015.Thenewguidelinescreateasharedunderstandingofoversightandmonitoringofpsychotropicmedicationpracticesforbothchildwelfareservicesandmentalhealthservices.Theguidelinessetexpectationsforphysicians,socialworkers,maturechildrenandyouth,parents,caregivers,Tribalmembers,andallotherpsychotropicmedicationstakeholderstocollaborateinstrengtheningtheoversightandmonitoringofpsychotropicmedications("Californiaguidelines,"2015).All-CountyInformationNoticeNo.1-05-14providesdetailsaboutsharingrequiredinformationwithcaregiverstofacilitatetheirinvolvementinprovidingcareforchildrenandyouth.
SenateBill238,signedintolawbyGovernorBrownonOctober6thof2015stipulatesthatcertainprofessionalsandotherswhoworkwithchildrenandyouthinfostercareshouldbeprovidedtrainingaboutimportanttopicsrelatedtotheadministrationofpsychotropicmedicationtothosechildrenandyouth.Specifically,trainingaboutpsychotropicmedicationandtraumaasrelatedtochildrenandyouthinfostercareistobeprovidedtogrouphomeadministrators,fosterparents,childwelfaresocialworkers,probationofficers,publichealthnurses,dependencycourtjudgesandattorneys,courtappointedcounselandspecialadvocatesalongwithinformationaboutbehavioralhealthandsubstanceuse.
Severalmediasourcesandotherstudieshaverecentlyrevealedthattherateofpsychotropicmedicationprescriptionsforchildrenandyouthinfostercareishigherthanthegeneralpopulation.Analarmingnumberofchildrenhavebeenprescribedmultiplepotentclassesofdrugstobetakensimultaneously.Thiscoverageandothermovementstoimprovementalhealthservicesinfostercareproducedseveralreformlaws.Theselawsmakeexplicitthatchildrenandyouthinfostercare,alongwiththeirfamiliesandrepresentatives,mustbeallowedtoprovideinputintowhetherornotpsychotropicmedicationispartoftheirtreatmentplan.
Ratherthanworkingfromtheassumptionthatsymptomsandbehaviorsarenecessarilyindicativeofmentalillness,thesereformsencouragetheuseofatrauma-informedlenstoviewthechild’senvironmentandexperiencesaspossiblesourcesofbehaviororsymptomsandtoexploreabroadrangeoftreatmentoptions.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 5
Psychotropicmedicationsareonetoolamongmanythatmaybeusedtoaddressbehavioralhealthconcerns.Theymustbeconsideredverycarefullyasthelong-termeffectsofthesemedicationsondevelopingbrainsisunknownandpotentialsideeffectscanbesevere.
Atthetimeofthiswriting,theCaliforniaDepartmentofSocialServicesisengagedinthedevelopmentoftheCaliforniaChildWelfareCorePracticeModel,whichsubsumesthePathwaystoMentalHealthServicesCorePracticeModelwithinalargerpracticeframeworkthatintegratesthechildwelfaresystemwithotherchild-andfamily-servingsystemsinthepublicsectorandtheirpartners.Inturn,theCaliforniaChildWelfareCorePracticeModelispartofatripartite“SharedApproachtoCalifornia’sChildren,Youth,andFamilies”withthepublicsystemsofbehavioralhealthandjuvenilejustice,whicharealsoinprocessofdevelopingpracticemodelsfortheirrespectivefieldsofpractice.An“IntegratedStatewideTrainingPlan”iscurrentlyunderwaywhichwillreflectthepracticeandservicedeliveryenvironmentsofthechildwelfare,behavioralhealth,andjuvenilejusticesystemsunderthe“SharedApproach.”ThiscurriculumiscongruentwiththedevelopingCaliforniaChildWelfareCorePracticeModelandwiththeforthcoming“IntegratedStatewideTrainingPlan.”TheCorePracticeModel(CPM)setsthefoundationforacommonpracticeframeworkthatintegratesbehavioralhealthscreenings,referrals,serviceplanning,servicedelivery,andoverallcoordinationandcasemanagementamongallthoseinvolvedinworkingwithchildrenwhoreceiveservicesfromchildwelfareandbehavioralhealthsystemsinthepublicsector.Theeffectiveengagementoffamiliesinthereferralandtreatmentprocessfortheirchildrenisintegraltothismission.TheCPMdescribesstandardsandexpectationsforpracticebehaviorsbychildwelfareandbehavioralhealthstaffthatensuresandsupportsmeaningfulparticipationbyfamiliesinthecareandtreatmentoftheirchildren.ChildandfamilyteamingisaservicerequirementforchildrenwhoqualifyforIntensiveCareCoordination,andwillsoonbethestandardthroughoutchildwelfare.Forchildrenandyouthwithidentifiedmentalhealthissues,childandfamilyteamingisstronglyrecommended.Childrenandyouthforwhompsychotropicmedicationisbeingrequestedfromthecourtwilllikelyfallintooneofthesecategories.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 6
CurriculumIntroduction
Duration:OneDay(9:00am-4:00pm,one-hourlunchbreak,two15-minutebreaks)
Thiscurriculumprovides:• Anoverviewoftheuses,benefits,andrisksofpsychotropicmedication.• Informationabouttraumaandhowitcaninformcareandtreatmentdecisions.• Guidanceforprofessionalstocreatetreatmentplansandteamwithfamiliesandotherprofessionalsto
makeandmonitortreatmentdecisions(e.g.,publichealthnurses,behavioralhealthproviders,schoolpersonnel,doctors,juvenileprobationofficers,CASAs,andotherindividualsinthefamilysupportnetworksuchascoaches,clergy,etc.).
• Howtolocateandusetheformsandinformationalmaterialsinthecourtapprovalprocess(JV-220).
ThecoreresourceforthistopicistheCaliforniaGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCare.Themostupdatedversionwillbeavailableat:http://www.dhcs.ca.gov/provgovpart/pharmacy/Documents/QIP_Guidelines.pdf
TheGuidelinesoutline• Basicprinciplesandvalues,• Expectationsregardingthedevelopmentandmonitoringoftreatmentplans(emotionalandbehavioral
healthcare,psychosocialservicesandnon-pharmacologicaltreatments),• Principlesforinformedconsenttomedication,and• Principlesgoverningmedicationsafety.
California’sPathwaystoMentalHealthpracticemodelisalsoahelpfulresource.Themostrecentversionofwhichmaybefoundhere:http://www.dhcs.ca.gov/Documents/KACorePracticeModelGuideFINAL3-1-13.pdf
AsistheCaliforniachildwelfarecorepracticemodel(CPM),themostrecentversionofwhichcanbefoundhere:http://calswec.berkeley.edu/california-child-welfare-core-practice-model-0
Theessentialdocument,theFosterCareYouth’sMentalHealthBillofRights,canbefoundhere:http://www.childsworld.ca.gov/res/pdf/QIP_PUB488.pdf
TheCaliforniaRulesofCourt5.640,whichgoverntheJV-220courtprocesscanbefoundat:http://www.courts.ca.gov/cms/rules/index.cfm?title=five&linkid=rule5_640
Acceptedpracticeandlocalrulesofcourtvaryacrosscounties,andthesematerialswillnotcoverallthesevariances.Knowingthespecificpracticesofthecountyforwhichyouareworkingisanimportantresponsibility,especiallywhenworkingwithchildrenandyouthwhohavementalorbehavioralhealthneeds.
Thiscurriculumisdevelopedwithpublicfundsandintendedforpublicuse.Useofcurriculumcontentshouldbecitedas:CaliforniaSocialWorkEducationCenter.(Ed.).(2016).PsychotropicMedicationinFosterCare.Berkeley,CA:CaliforniaSocialWorkEducationCenter.
Forquestionsregardingthecurriculum,contactShayK.O’Brien,[email protected],[email protected],orcallCalSWECat510-642-9272.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 7
Agenda
Segment1 WelcomeandIntroductions
Segment2 LawsandRegulations
Segment3 CourtProcessandForms
BREAK
Segment4 Trauma
Segment5 AccessingServices
LUNCH
Segment6 PsychotropicMedication
BREAK
Segment7 UsingtheCaliforniaGuidelines
Segment8 Wrap-UpandEvaluations
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 8
LearningObjectives
Knowledge
K1:TraineeswillbeabletonameatleastthreekeypointsinthelawsandregulationsthatgovernadministrationofpsychotropicmedicationstochildrenandyouthinfostercareinCalifornia.
K2:Traineeswillbeabletonameatleastoneofthebasicprinciplesoftrauma-informedcareastheyrelatetouseofpsychotropicmedicationinfostercare.
K3:Traineeswillbeabletonameatleasttwocommonbehavioralhealthdiagnosesandtherelatedtreatmentoptions(bothpsychosocialandmedical)forchildren,youth,andyoungadultsinfostercare.
K4:Traineeswillbeabletodescribewhatdotoifsideeffectsarenoticedorreportedbyachild,youth,oryoungadultinfostercarewhoistakingprescribedpsychotropicmedication.
K5:Traineeswillbeabletolocateandutilizethecorrectstaterequiredforms(JV-217throughJV-224)whenamedicalproviderisstartingorcontinuingapsychotropicmedicationforachildoryouthinfostercare.
K6:Traineeswillbeabletodescribethenotificationprocessesusedinrequestingandmonitoringadministrationofpsychotropicmedications.
Skills
S1:Usingsampleplans,traineeswillutilizetheCaliforniaGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCareandthetoolsinitsappendicestoevaluateandmodifytreatmentplansthatincludepsychotropicmedicationdecisions.
a. PrescribingStandardsbyAgeGroup,b. ParametersforUseofPsychotropicMedicationforChildrenandAdolescents,c. ChallengesinDiagnosisandPrescribingPsychotropicMedication,andd. Algorithm/DecisionTreeforPrescribingPsychotropicMedication.
S2:Usingavignette,traineeswillbeabletoidentify:
a. Therelevantpartiesanddocumentationtobeincludedinthecourtprocess,b. Thoseparties’rightsandobligations,andc. Thetimelineforcourtrequests,decisions,andnotifications.
Values
V1:Traineeswillvaluebuildingonchildandfamilyresilienceandstrengthsinbothformalandinformalservicesusedtoamelioratethenegativeeffectsof
a. abuseand/orneglect;b. emotional,cognitive,and/orbehavioraldysregulations;andc. potentialmentalillness.
V2:Traineeswillvalueensuringthatthevoicesofchildren,youth,andyoungadultsareincorporatedintotreatmentplansandmedicationdecisions.
V3:Traineeswillvalueworkingwithamulti-disciplinaryteamtounderstandandmanagetheuseofpsychotropicmedicationbychildren,youth,andyoungadultsinfostercare.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 9
Segment1:WelcomeandIntroductions
Pleaseintroduceyourselfbyproviding
• Yourname• Yourcounty/department/agency/unit• TheroleyouplayinFosterCare
Activity:GroupAgreements
Someexamplesoftheseagreementsare:
• Respecteachother’sperspectivesandexperience.• Mindfullyparticipatebykeepingtheenvironmentcollegialandproductive.• Ifanissuearises,addresstheinstructorontheside,one-on-one,ratherthaninfrontofthewholegroup.• Avoidinterrupting,ridiculing,ortalkingovereachother.• Considerprivacyandconfidentialityconcernscarefullybeforeyoudiscussanycaseoruseacurrentor
formercaseasanexample.
Youmayusethisspacetomakenoteoftheagreementsyourgroupmakes.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 10
Segment2:LawsandRegulations
DefinitionofPsychotropicMedication
IntheWelfareandInstitutionsCode,psychotropicmedicationsaredefinedas:“Thosemedicationsprescribedtoaffectthecentralnervoussystemtotreatpsychiatricdisordersorillnesses.Theymayinclude,butarenotlimitedto,anxiolyticagents,antidepressants,moodstabilizers,antipsychoticmedications,anti-Parkinsonagents,hypnotics,medicationsfordementia,andpsychostimulants.”
TheCaliforniaDepartmentofSocialServicesandtheDepartmentofHealthCareServiceshavechosenthisdefinitionintheirGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCaredocument,whichwewilluselaterintheday.
BigPicture
Concernsthathavebeenraisedbyresearchstudies,governmentreportsandmediacoverageinclude:over-medication,off-labelmedication,multipleprescriptions,insufficientmonitoring,andmedicatingveryyoungpatients.
Researchandmediasourcesrevealthattherateofpsychotropicmedicationprescriptionsinfostercareishigherthanthegeneralpopulation,childrenhavebeenprescribedmultiplepotentclassesofdrugstobetakensimultaneouslyandwithoutascheduletoevaluateeffectiveness(inotherwords,permanently).Thiscoverageandothermovementstoimprovementalhealthservicesinfostercareproducedseveralreformlaws.Input:Theselawsmakeexplicitthatchildrenandyouthinfostercare,alongwiththeirfamiliesandrepresentatives,mustbeallowedtoprovideinputintowhetherornotpsychotropicmedicationispartoftheirtreatmentplan.Trauma:Ratherthanworkingfromtheassumptionthatsymptomsandbehaviorsarenecessarilyindicativeofmentalillness,thesereformsencouragetheuseofatrauma-informedlenstoviewthechild’senvironmentandexperiencesaspossiblesourcesofbehaviororsymptomsandtoexploreabroadrangeoftreatmentoptions.Broadarrayofservices:Psychotropicmedicationsareonlyonetoolamongmanythatmaybeusedtoaddressbehavioralhealthconcerns.Theymustbeconsideredverycarefullyasthelong-termeffectsofthesemedicationsondevelopingbrainsisunknownandpotentialsideeffectscanbesevere.Goalistogetappropriate,quality,accessiblemental/behavioralhealthservicestochildrenandyouthincare.
SenateBill238
Courtauthorizationprocess• Onlyajuvenilecourtjudicialofficercanordertheadministrationofpsychotropicmedicationstoachildor
youthinfostercare(exceptrarecaseswe’llcoverlater)• Thatofficermayonlydosobaseduponarequestfromaphysician.• Thatphysicianwillprovidereasonsfortherequestandadescriptionofthechild’sdiagnosisand
symptoms.• Thecourtwillreceiveinformationaboutthechild’soverallmentalhealthassessmentandtreatmentplan,
andprocessforperiodicoversightandevaluationtobefacilitatedbythesocialworker,publichealthnurseorothercountystaff.
• Caregiverreceivesnoticewithintwodaysofcourt’sdecision
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 11
ChildandFamilyInput• Providesopportunityforthechildandhisorherfamilyandcaregiver,court-appointedspecialadvocate,
thechild’stribe,orotherstoprovideinputonthemedicationsbeingrequested.• Requiresthatthechild’scaregiverreceiveacopyofanyresultingcourtorder.
PublicHealthNurses• SB238clarifiesthepublichealthnursingprograminchildwelfarewiththepurposeofpromotingand
enhancingthephysical,mental,dental,anddevelopmentalwell-beingofchildreninthechildwelfaresystem.
• PHNswillcollectanddocumentmedicalrecords,assistwithreferrals,andparticipateinmedicalcareplanningandcoordination.
MonthlyStateData• RequirestheCaliforniaDepartmentofSocialServicesisrequiredtoissueamonthlyreporttoindicate
whenredflagsarepresent.Forexample,o whenmultiplemedicationsareprescribedforthesamechild,oro whenunusuallyhighdosesareindicated,oro whenprescriptionsareforchildrenwhoare5yearsoldoryounger.
• Countiesaresubsequentlyrequiredtosharerelevantinformationwithappropriatejuvenilecourt,attorneys,countydepartmentofbehavioralhealth,andCASAs.
Recommendsthistraining• SB238suggeststrainingabouttheauthorization,uses,risks,andbenefitsofpsychotropicmedicationas
wellastrainingonself-administration,oversight,andmonitoringofthosemedications.• Thelawsuggeststhatthetrainingincludeinformationabouttrauma,substanceusedisorder,andmental
healthtreatments.
SenateBill319
SenateBill319addressestheroleofFosterCarePublicHealthNurses.
Publichealthnurseswill:• monitoruseofpsychotropicmedicationbychildrenandyouthinfostercare,• documentinitialandfollow-uphealthscreenings,• collecthealthinformationtodetermineappropriatereferral,• helpchildrenandfamiliesconnectwiththeservicestheyneed,• assistwithtreatmentplanning,• assessprogresstowardtreatmentgoals,and• advocatetoensurethatthehealthneedsofthechildaremetandthatthechildandfamilycanmake
informeddecisionsabouttheirownmedicaltreatmentandhealthcaregoals.
Thespecificpracticesandprotocolsfortheseactivitieswillvaryaccordingtocountydecisions.
SenateBill484
ThislawappliesprimarilytoGroupHomes.Runawayandemergencysheltersareexemptedfromtherequirementsofthisbill.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 12
Grouphomesarerequiredtousepsychotropicmedicationinaccordancewiththewrittendirectionsoftheprescribingphysicianasauthorizedbythejuvenilecourt.
GroupHomesaretomaintainspecificinformationinthechild’srecords• Acopyofthecourtorderthatauthorizestheadministrationofprescribedmedication• Aseparatelogforeachmedicationthechildistakingthatincludes:
ü thenameofthemedication,ü thedateofprescription,ü thequantityofmedicineandthenumberofrefills,ü dosageanddirections,andü thedateandtimewhenthechildtookeachdose.
Thislawalsodelineateshowthestatewillidentifygrouphomesthatwarrantadditionalreviewandmandatesvisitsatleastonceayeartoidentifiedfacilities.
SB484authorizesthedepartmentofsocialservicestoshareinformationaboutthesevisitswithcountyplacingagencies,socialworkersandprobationofficers,thecourt,anddependencycouncilortheMedicalBoardofCalifornia.
GrouphomeswhohavehadavisitorreportwillbeallowedtosubmitimprovementplanstoCDSSwithin30daysofthatvisit.
GrouphomeswillberequiredtoimplementalternativeprogramsandservicesthatadheretonewperformancestandardsandoutcomemeasurestobedesignedbyCDSSbyJanuary1,2017
LegislativeUpdates
SenateBills• 1174—prescriber-oversightbillallowingMedicalBoardofCaliforniatoexamineprescriptionpatterns• 1291—improvestransparencyandtrackingofmentalhealthservicesforchildrenandyouthinfostercare
InformationaboutnewCalifornialawsconcerninghealthcanbefoundhere:http://www.dhcs.ca.gov/formsandpubs/laws/Pages/LawsandRegulations.aspx
LinkstotheinvestigativejournalismdonebySanJoseMercury-Newscanbefoundhere:http://www.mercurynews.com/tag/drugging-our-kids/
SupplementalMaterials:
• StateAuditSummary• ACF,Children’sBureauInformationMemorandum12-03• FulltextofSB238• FulltextofSB319• FulltextofSB484• ACL16-48RoleofFosterCarePublicHealthNurses
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 13
Segment3:CourtProcessandForms
CourtProcess
MuchoftheworkdonebytheCFTorothertreatmentteamespeciallythehealthhistory,pasttreatmentsdocumentationandrisk/benefitanalysis,willbeusefulforthecourtifpsychotropicmedicationisselectedaspartofthetreatmentplan.ThenewcourtprocessusedtoconsiderarequestedpsychotropicmedicationbeadministeredtoachildoryouthincarebecameeffectiveonJuly1st,2016.Itstrengthensthecontinuity,quality,andcoordinationofcare.Continuityisimprovedbythesharingofmedicalandtreatmenthistoryacrossagencies,qualityofcareisenhancedbyimprovedmonitoringandclearexpectations,andcoordinationiseasierbecausesocialworkersandpublichealthnurseshaveeasieraccesstonecessaryinformation.
JudicialReview
Bylaw,achildwhoisawardordependentofjuvenilecourtorinfostercaremaynotreceivepsychotropicmedicationwithoutacourtorder.TheJudicialCouncilhascreatedaseriesofformsusedtorequestthisorderfromthecourt.Theymakeupthe“JV-220Process.”Thereareonlythreeexceptionstothismandate.Oneexceptionisifthechildoryouthlivesinanout-of-homefacilitythatisnotconsideredfostercare.Anotherexceptioniswhenthereisapreviouscourtorderthatgivesthechild’sparentstheauthoritytoapproveorrefusethemedication.Thefinalexceptionisinthecaseofanemergency.Adoctormayadministerpsychotropicmedicationtoachildiftheyposeaseriousrisktothemselvesorothers,topreventdeathorseriousharm,orifwaitingwouldcreatesignificantsuffering.Afteremergencyadministrationofmedication,thedoctorhasnomorethan2daystoseekcourtauthorizationthroughtheJV-220process.Judicialapprovalissoughtbythesocialworkerorprobationofficerwiththechild’sprescribingphysician.Theyworkincollaborationwiththechild,hisorhercourtandtribalrepresentatives,alongwithfamilymembersandcaregivers.PublicHealthNursesarekeymembersoftreatmentteamsforchildrenandyouthinfostercare.CivilCodesection56.103statesthatmedicalinformation,barringpsychotherapynotes,andotherrestrictedhealthinformationmaybesharedwithPublicHealthNursesorPHNs,buttheRulesofCourtthatdelineatetheJV-220processdonotincludePHNsexplicitly.CountieswillvaryintheapproachtheytaketoincorporatingtheroleofPHNsandthedatasharingactivities
Exceptions
Judicialapprovalisrequiredexceptinthesecircumstances.• Continuationofmedicinefrombeforetheywereinfostercare.• Parent/legalguardianremainstheonlypersonallowedtoconsenttotreatment.• Emergency—rareandshort-term• Non-MinorDependentshavetheirownconsenttograntordeny,Courthasnoauthority• Childoryouthislivinginout-of-homeplacementnotconsideredfostercare(e.g.juveniledetention
orvoluntaryplacement)
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 14
RequiredForms
Hereisaquickintroductiontotheformsusedinthecourtapprovalprocessforrequestingandadministeringapsychotropicmedicationtoachildinfostercare.Useofthemissometimescalledthe“JV-220Process.”• JV-220istheformthatinitiatestherequesttoadministerpsychotropicdrugstoachildoryouthincare.• JV-220(A)isanattachmenttotheJV-220andcontainsthephysician’sstatement.Itmustaccompanythe
JV-220,unlesstherequestistocontinueanongoingtreatmentwithoutchangesandisrequestedbythesamedoctor.Inthatcase,JV-220(B)shouldbeattached.TheseJV-220formsarecommonlyreferredtoastheApplication.
• JV-221istheformthatshowstheCourtthatallpartieswitharighttoreceivenoticewereservedacopyoftheApplicationandattachments.Wewillcoverthesepartiesmorethoroughlyinafewmoments.
• JV-223istheOrderontheApplicationandistheformtheCourtusestoeithergrantordenytheApplicationforPsychotropicMedication.
• JV-224isfiledwiththeCourtbythesocialworkerorprobationofficeratleast10calendardaysbeforeeachprogressreview.
• JV-217INFOisaGuidethatprovidesbriefdescriptionsofalltheformsrelatedtotheApplicationforPsychotropicMedication.ItissentalongwithnotificationsofapendingApplication.
OptionalForms
Inadditiontotherequiredforms,therearesomethatthefamilyandtreatmentteammaydecidetouse.Itisimportanttonotethatwhiletheseformsarelistedas“optional,”thatdoesnotmeanthatseekingtheinputoftheseindividualsisoptional.Itisjustthattheuseofthesespecificformsisnotrequired.Involvedpartiesmaycommunicatetheirthoughtsandfeelingsusingothermeans,buttheirinputshouldbesought.TheJV-218formcanbeusedbythechildforwhomthemedicationisrequested.ItisoneofavarietyofmethodsthechildmayusetoprovidetheirinputtotheCourt.JV-219isasimilarformthatmaybeusedbythecaregiver,CASA,orTribetoprovideastatementabouttheirfeelingsrelatedtotheApplicationforadministrationofapsychotropicmedicationtothechildinquestion.JV-222formisfiledwhentheparentorguardian,theattorneyofrecordforaparentorguardian,thechild,thechild’sattorneyorguardianadlitem,ortheIndianchild’sTribedoesnotagreethatthechildshouldtaketherecommendedmedication.
SupplementalMaterials:• JV-220FormsprovidedbyTrainer• JV-220HandoutsprovidedbyTrainer• CaliforniaRulesofCourt5.640• AmericanBarAssociation—PsychotropicMedicationandChildreninFosterCare:Tipsfor
AdvocatesandJudges
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 15
Segment4:Trauma
DefinitionofTrauma
SubstanceAbuseMentalHealthServicesAdministration’sdefinitionoftrauma:
“Individualtraumaresultsfromanevent,seriesofevents,orsetofcircumstancesthatisexperiencedbyanindividualasphysicallyoremotionallyharmfulorthreateningandthathaslastingadverseeffectsontheindividual’sfunctioningandphysical,social,emotional,orspiritualwell-being.”
Theinclusionof“setofcircumstances”incorporatestheexperienceofneglect,whichisthemostfrequentreasonthatchildrenandyouthareremovedfromtheirhomes.Therefore,thisdefinitionisimportantforworkwiththefostercarepopulation.Itdoesn’tcompletelyalignwiththediagnosticcriteriaforPTSD,sothisisanareathatrequiresattention.Thetrauma-informedapproachisofparticularimportancewhenwearediscussingmentalandbehavioralhealthinterventions.Often,thesignsandsymptomsoftraumacanresemblethoseofmentalillnessorbehaviordisorders.Thesesymptomsandbehaviorsmightthenbetreatedasamentalillnessorchemicalimbalanceand/orwithpsychotropicmedications,thuscausingmissedopportunitiestoaddressthetraumaaswellasincreasingthelikelihoodofaddingunduestressorevenre-traumatizingtheindividual.
ThethreeE’softrauma
Thisdefinitionhighlightsthethreecomponentsoftrauma,whicharetheeventorthecircumstance,theexperienceoftheevent,andtheeffectoftheexperience.THEEVENT:Thesourceofpotentialtraumaisaneventorcircumstancethatcausessignificantstress.Noteverychildexposedtostresswilldeveloptrauma.Examplesmayincludetheactualorextremethreatofphysicalorpsychologicalharmorsevere,life-threateningneglect.Theseeventsandcircumstancesmayhappenasasingleoccurrenceorrepeatedlyovertime.Traumacanalsooccurwhenanindividualwitnessesextremethreatsorstressfulcircumstancesexperiencedbysomeonetheycareabout.EXPERIENCE:Thesingularexperienceanindividualhasoftheseeventsorcircumstancesdetermineswhetheritisatraumaticevent.Aparticulareventmaybetraumaticforoneperson,butnotforanother.Feelingsofpowerlessness,humiliation,guilt,shame,betrayal,orsilencingoftenshapetheexperienceoftheevent.Howtheeventisexperiencedmaybelinkedtoarangeoffactorsincludingtheindividual’sculturalbeliefs,availabilityofsocialsupports,ordevelopmentalstageatthetimetheeventoreventsoccurred.EFFECTS:Acriticalcomponentofdeterminingifanexperiencewastraumaticforanindividualisthepresenceoflong-lastingandadverseeffects.Theymayoccurimmediately,ornot.Sometimesadverseeffectsarenotnoticeduntilmuchlater,butarenonethelesscausedbythepreviousEventsandExperiences.
TraumaandFosterCare
Childrenandyouthcurrentlyorformerlyinfostercarehavelivedthroughatleastoneeventwhichcouldbetraumaticforthem:theywereremovedfromtheirhome.Theylostaccesstotheirfamilyforatleastsometime.Serviceswithinthefostercaresystem,whicharedesignedtoprotectchildrenfromharm,can—inandofthemselves—betraumatizing,despiteourbestefforts.Forexample,removalfromtheirhome,separationfromsiblings,pets,andfamiliarenvironment,chaoticplacement,etc.Thereisalsothesignificantloss,abuse,and/orneglectthatthechildexperiencedwhichresultedinremovalfromtheirhome.Anyoftheseeventscancausetrauma.Therefore,itmakessensetoviewthispopulationthroughthelensofpotentialtraumaanditseffects.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 16
Symptomslikesleepproblems,toiletingproblems,anger,aggressivebehaviors,depression,ordifficultysustainingattentionareallidentifiedbytheAmericanAcademyofPediatrics(2015)aspossiblepresentationsfromchildrenwithahistoryofadverseandpotentiallytraumaticexperiences.
That’swhyitisimportanttocarefullyscreenforandevaluatetraumawhenassessingtheneedsofchildrenoryouthandtokeepinmindthatchildrenaredoingthebesttheycanwiththecircumstancesthey’vegot.
Problematicbehaviorsandsymptomswillnotalwaysshowupimmediatelyfollowingtraumaticevents.Itmaytakemanyyearsforsymptomsoftraumaticexperiencestobecomeapparent.Itisnotuncommonforadolescencetobeatimewhenchildhoodtraumaisrevealedinphysiologicaland/orbehavioralsymptoms.Individualresponsesvarywidely,soitisimportanttocarefullyandcompassionatelyassesssymptomsandbehaviorsthroughatrauma-informedlensevenifnothingobviouslytraumatichashappenedrecentlyinthechild’slife.
TraumaandResilience
Unaddressedtraumasignificantlyincreasestheriskofmentalhealthconcerns,substanceusedisordersandchronicphysicaldiseases.Thesepotentialoutcomescanbemitigatedbyresilience.Resilienceiscomprisedofthreeinteractiveinfluences:1. Individualdifferencesintemperamentandcognitiveabilities2. Qualityofsocialrelationships—doesthechildhavepeersandadultstheycantrustandwhocareabout
them?3. Qualityofthebroaderenvironment,suchasschoolandneighborhoodResiliencecanbenoticed,heightened,andcenteredbytheuseofastrengths-basedapproachtoworkwithchildrenandfamilies.Focusingontheassetsandtoolsthatindividualsalreadypossessratherthanperceiveddeficitscanempowerindividualsandminimizelabelsandstigmas.Identifyingandbuildingonthestrengthsoftheindividual,theirsupportnetwork,andtheirenvironmentincreasesresilienceandcanimprovetheprotectivefactorsindealingwithpastandpotentialfuturetraumaandhelptomitigatenegativeeffectsfromstress.
NegativeEffectsofTrauma
Examplesofnegativeeffectsincludelimitedordisruptedabilityto:• copewiththenormalstressesandstrainsofdailyliving,• formrelationshipsormaynotbeabletotrustinorbenefitfromthem,• managecognitiveprocesses(suchasmemory,attention,thinking),• regulatebehavior,or• controltheexpressionofemotions.
Thesebehaviorsmaybeadaptiveandprotectivewhenthechildisinthestressfulenvironment,butcanbemisunderstoodaspathologicwhentheyareremovedfromthatenvironment.Noteverydysregulationisindicativeofadisease.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 17
Thesenegativeeffectscansometimestaketheformofanger,violence,self-harm,distrustfulness,hypervigilance,numbness,substanceuse,nightmares,avoidance,and/orhopelessnessandtheycanwearapersondownphysically,mentally,andemotionally.Neurobiologyandongoinghealthandwell-beingmaybepermanentlyaltered.Survivorsoftraumahavealsohighlightedtheimpactoftheseeffectsonspiritualbeliefsandthecapacitytomakemeaningoftheseexperiences.Youmayhavenoticedthatallthesesymptomsresemblesymptomscommonlyassociatedwithmentalorbehavioralhealthdiagnoses.Traumaandmentalhealthoftenoverlap.Traumacanhavenegativeeffectsonachild’spsychologyand,conversely,mentalhealthissuescanincreasevulnerabilitytotrauma.Traumashouldbeconsideredatallpointsinmentalhealthandsubstanceuseservicesincludingprevention,treatment,andrecovery.
TraumaandSubstanceUse
Interrelatedandrisksgobothdirections.• Substanceuseasanattempttomanagetraumasymptoms(self-medicatingtheory).• Traumaoccursasresultofsubstanceuseandmaybemorelikely(youngpeopleusingsubstancesare
morelikelytoengageinriskybehaviorsandbenearpotentiallyabusiveordangerouspeople,mayberequiredtodoillegalthingstosupportaddiction,etc.).
• Similarpatternsanddysregulationinaddictionandtraumaticstress.Prioritizeintegratedandspecializedservices• Thesecanbechallengingtolocate,butarearequiredcomponentofMediCalviaEPSDT(seeMHSUDS
InformationNotice16-063intheSupplementalMaterials).• Integrationandresource-sharingcanoccurontreatmentteam.• Acknowledgingtraumaanditsrelationshipwithsubstanceusecanbeanempoweringaspectoftreatment
andrecovery.Youthmayengageinriskybehaviorsasaresultofuseandexperienceatraumaticeventand/ormaybelessabletocopewithatraumaticeventduetosubstanceusethantheirnon-usingpeers.Someserviceswon’tacceptfolkswhoareusingdrugsoralcoholintotheirmentalhealth/traumaservices,andPTSDissometimesanexclusioncriterionforsubstanceusetreatment.Treatmentteamswithprofessionalsfrombothareascanhelpmakesuretheservicesarecomplimentary.
Trauma-InformedToolsandServices
Thetrauma-informedapproachisofparticularimportancewhenwearediscussingmentalandbehavioralhealthinterventions.Often,thesignsandsymptomsoftraumacanresemblethoseofmentalillnessorbehaviordisorders.Thesesymptomsandbehaviorsmightthenbetreatedasamentalillnessand/orwithpsychotropicmedications,thuscausingmissedopportunitiestoaddressthetraumaaswellasincreasingthelikelihoodofaddingunduestressorevenre-traumatizingtheindividual.Whenassessingchildrenandyouthforservices,atrauma-informedapproachisimportantbecause:• Symptomscanbecopingmechanismsoradaptiveresponses.• Carefulassessmentiscrucialtoeffectivetreatment.• Thelongertraumaticstressgoesuntreated,thegreatertheriskofdevelopingmaladaptiveandpotential
dangerouscopingmechanisms.• Symptomsusedtofinddiagnosesoftenoverlapwithsymptoms/behaviorsresultingfromtrauma.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 18
SymptomsthatOverlap:ChildTraumaandMentalIllness
Attentiondeficit/hyperactivitydisorder(ADHD)Restless,hyperactive,disorganized,and/oragitatedactivity;difficultysleeping,poorconcentration,andhypervigilantmotoractivity
Oppositionaldefiantdisorder(ODD) Apredominanceofangryoutburstsandirritability
Anxietydisorder(incl.socialanxiety),obsessive-compulsivedisorder(OCD),generalizedanxietydisorder(GAD),orphobia
Avoidanceoffearedstimuli,physiologicandpsychologicalhyperarousaluponexposuretofearedstimuli,sleepproblems,hypervigilance,andincreasedstartlereaction
Majordepressivedisorder(MDD)Self-injuriousbehaviorsasavoidantcopingwithtraumareminders,socialwithdrawal,affectivenumbing,and/orsleepingdifficulties
BipolarDisorder
Hyperarousalandotheranxietysymptomsmimickinghypomania;traumaticreenactmentmimickingaggressiveorhypersexualbehavior;andmaladaptiveattemptsatcognitivecopingmimickingpseudo-manicstatements
PanicDisorderStrikinganxietyandpsychologicalandphysiologicdistressuponexposuretotraumaremindersandavoidanceoftalkingaboutthetrauma
SubstanceAbuseDisorderDrugsand/oralcoholusedtonumboravoidtraumareminders
PsychoticDisorder
Severelyagitated,hypervigilance,flashbacks,sleepdisturbance,numbing,and/orsocialwithdrawal,unusualperceptions,impairmentofsensoriumandfluctuatinglevelsofconsciousness.
Note.AdaptedfromAddressingtheimpactoftraumabeforediagnosingmentalillnessinchildwelfares.International,byGriffin,etal.(2011),ChildWelfare,90(6),69–89.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 19
Activity:SmallGroupDiscussion
1. Whataresomeexamplesofachild’sresilienceinthefaceoftrauma?Oratimewhenastrengths-basedapproachwasusedsuccessfullytoaddresstrauma?
2. Doyouordoesanyoneinyourgroupuseformaltraumaassessmentsorothertrauma-specifictools?Whatabouttrauma-informedserviceproviders?
Ifso,howaretheyused?Whatarethesuccessesandchallengesofhavingthisinformationandapproach?
Ifnot,doyouthinkitwouldbeusefultohavethesetools?Howwouldyouusethem?Howcanyougettheminyourcounty/agency?
SupplementalMaterials:
• SAMHSA’sConceptofTraumaandGuidanceforaTrauma-InformedApproach• AmericanAcademyofPediatricsHelpingFosterandAdoptiveFamiliesCopewithTrauma• NationalRegistryofEvidence-BasedProgramsandPracticesBehindtheTerm:Trauma• NationalChildTraumaticStressNetwork’sTraumaandSubstanceAbuse• NationalChildTraumaticStressNetwork’sTipsforFindingHelp• ChadwickTrauma-InformedSystemsProject:EssentialElements
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 20
Segment5:AccessingServices
Person-CenteredApproach
Becausetraumaandstrengthsaresouniquetoeachindividual,assessmentandtreatmentplanningrequiretheuseofaPerson-CenteredApproach.Thisapproachcanbedefinedas:
“ahighlyindividualizedcomprehensiveapproachtoassessmentandservicesthatisfoundedonanunderstandingoftheperson’shistory,strengths,needs,andvisionofhisorherownrecoveryandincludesattentiontoissuesofculture,spirituality,trauma,andotherfactors.”
Forchildrenandyouthinfostercare,someotherfactorstoobservearegriefandloss,sexualorientation,genderidentityandexpression,andanythingelsethatthechildoryouthtellsyouisimportant.Thisapproachsharestheplanning,development,andmonitoringofserviceswiththepersonforwhomtheservicesareintended.
AccessingServices
AllchildrenandyouthinfostercareareeligibleforEarlyandPeriodicScreening,Diagnosis,andTreatment(EPSDT).TheEPSDTProgramisacomprehensivebenefitpackagewithinMedicaidspecificallyforchildrenuptoage21.Itincludes:
• medical,• dental,• substanceusedisordertreatment,and• mental/behavioralhealthcareservices.
AllchildreninvolvedwiththefostercaresystemareeligibleforfederalMedicaidbenefits,whichiscalledMedi-CalinCalifornia.TheEPSDTProgramemphasizespreventionandearlyintervention,andrequiresthatchildrenreceivecomprehensiveexaminationstoidentifyandaddresstreatmentneeds.ChildrenandyouthwhomeetmedicalnecessitycriteriaareeligibletoreceiveSpecialtyMentalHealthServices(SMHS).AccordingtotheMentalHealthandSubstanceUseDisorderServices(MHSUDS)InformationNotice16-061,inordertoreceiveSMHS,childrenandyouthmusthaveacovereddiagnosis—listedbelow—andmeetthefollowingcriteria:
1. Haveaconditionthatwouldnotberesponsivetophysicalhealthcarebasedtreatment;and
2. TheservicesarenecessarytocorrectorameliorateamentalillnessandconditiondiscoveredbyascreeningconductedbytheManagedCarePlan,theChildHealthandDisabilityPreventionProgram,oranyqualifiedprovideroperatingwithinthescopeofhisorherpractice,asdefinedbystatelawregardlessofwhetherornotthatproviderisaMedi-Calprovider.
Covereddiagnosesare:• PervasiveDevelopmentalDisorders,exceptAutisticDisorders• DisruptiveBehaviorandAttentionDeficitDisorders• FeedingandEatingDisordersofInfancyandEarlyChildhood• EliminationDisorders• OtherDisordersofInfancy,Childhood,orAdolescence
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 21
• SchizophreniaandotherPsychoticDisorders,exceptthoseduetoaGeneralMedicalCondition• MoodDisorders,exceptthoseduetoaGeneralMedicalCondition• AnxietyDisorders,exceptthoseduetoaGeneralMedicalCondition• SomatoformDisorders• FactitiousDisorders• DissociativeDisorders• Paraphilias• GenderIdentityDisorder• EatingDisorders• ImpulseControlDisordersNotElsewhereClassified• AdjustmentDisorders• PersonalityDisorders,excludingAntisocialPersonalityDisorder• Medication-InducedMovementDisordersrelatedtootherincludeddiagnoses.
Excludeddiagnoses(thoseforwhichtheMHPisnotresponsible):• MentalRetardation• LearningDisorders• MotorSkillsDisorder• CommunicationDisorders• AutisticDisorders(OtherPervasiveDevelopmentalDisordersareincluded)• TicDisorders• Delirium,Dementia,andAmnesticandOtherCognitiveDisorders• MentalDisordersDuetoaGeneralMedicalCondition• Substance-RelatedDisorders• SexualDysfunctions• SleepDisorders• AntisocialPersonalityDisorder
OthermentalhealthservicesavailablethroughMedi-Cal:
• TherapeuticBehavioralServices/Coach• IntensiveCareCoordination• IntensiveHome-BasedServices• TherapeuticFosterCare
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 22
InCalifornia,“non-specialty”mentalhealthservicesmaybeprovidedbyacounty’sManagedCarePlan.“Specialty”mentalhealthservices,mandatedEPSDT,areprovided(orarrangedtobeprovided)throughthecountyMentalHealthPlan.Belowarethetargetpopulationsandservicescoveredbyeach.
RightsofMedi-Calbeneficiaries
AllfamilieswithchildrenwhoareassessedforservicesunderEPSDTshouldreceiveaNoticeofActioninformingthemoftheresultsofthatassessment.TheNOAmaybedeliveredtothechildwelfareworker,andshouldbesharedwiththefamilyandthetreatmentteam.
Allcountymentalhealthplansmusthaveatoll-freenumber(listedbelow).
Beneficiarieshavearighttoreceive:• Ahandbookthatoutlineshowtofileagrievanceand/oranappealandwhatservicesareavailableto
them,and• Anelectronicversionofaproviderdirectorywithcontactinformation.
DeniedServices
Ifnecessaryservicesaredenied,terminated,reduced,ordelayedanappealmaybefiled.Contactyourcounty’sMHPortheHealthConsumerAllianceat888.804.3536orwww.healthconsumer.org.
TargetPopulationsandServices
Non-Specialty Mental Health Services Carved-in Effective 1/1/14
Mental Health Services� Individual and group mental health evaluation and treatment
(psychotherapy)�Psychological testing when clinically indicated to evaluate a
mental health condition�Outpatient services for monitoring drug therapy�Outpatient laboratory, medications, supplies, and
supplements�Psychiatric consultationAlcohol Abuse Services�Screening, Brief Intervention, and Referral to Treatment
Medi-Cal Managed Care Plans
(MCP)
County Mental Health Plan
(MHP)
Medi-Cal Specialty Mental Health Services
Outpatient Services�Mental Health Services (assessments, plan development,
therapy, rehabilitation and collateral, medication support)�Day Treatment services and rehabilitation�Crisis intervention and stabilization�Targeted Case Management�EPSDT specialty mental health services
Inpatient Services�Acute psychiatric inpatient hospital services�Psychiatric Health Facility services �Psychiatric Inpatient Hospital Professional Services if the
beneficiary is in a FFS hospital
Target Population: Children and adults eligible for outpatient non-specialty mental
health services ( mild to moderate conditions)
Target Population: Children and adults with disabling conditions that require mental health treatment (children; adults w/ severe cond.)
Medi-CalMentalHealthandSubstanceUseDisorderServices(MHSUDS)DeliverySystems
27
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 23
CorePracticeModelMental/BehavioralHealthScreeningFlow
ChildWelfareconductsBehavioralHealthScreening
IntakeandAnnually
EmergencyNeeds
Non-emergencyNeeds
NoCurrentBehavioralHealth
Needs
ChildWelfarereferstoCountyMental
HealthforWIC5150Evaluation
MonitorandEvaluateregularly
Screenagainatleast
annually
ChildandFamilyTeamdeterminesbestassessment.ANYqualifiedMediCalcliniciancanassess.
Then,countyMHPorManagedCarearrangefor/provideservices.
NOTE:Childrenandyouthwhoareassessedunder
EPSDTshouldreceiveaNoticeofActioninformingthemoftheresultoftheassessment.
Ifdeniedservices,thecaregivercanfile
anappeal.
Yes
BehavioralHealthnotifieslegalguardianandarrangesassessment
No
BehavioralHealthmeetswithChild
andFamilyTeamtostabilizeandsafety
plan
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 24
InformalServices
InformalMentalHealthServicesareactivitiesdeliberatelyintroducedtohelppromotehealingandalleviatesymptomsandtoprovidethechildoryouthopportunitiesfor:
• positivepeerinteraction,• self-discipline,• toleranceforfrustration,• enhancedself-esteem,• masteryofskills,• beingpartofsomethinglargerthantheirowncurrentcircumstance.
Theycanalsoprovideasupportiveadultwhomaybecomeamemberofthetreatmentteamorcanofferinsighttotheteam,likeacoachorinstructor.
Someinformalmentalhealthservicesthattheteammaychoosetoincludeinachild’streatmentplanarethefollowing:
• Exerciseorparticipationinorganizedorinformalsports,• Musicaltraininglikemusiclessons,choir,orband• Artorwritingclassesorindividualartisticexpression.• Participatingincommunitytheaterproductionsordramaactivitiesatschool• Interactingwithanimalscanbeverytherapeutic,ascanvolunteeringtohelpothers.• Meditation,changesindietandcookingorparticipatinginfoodpreparationandgardeningcanall
helpchildrenmanagestressandfeelconnected.
Involvementintheseactivitiesshouldnotbethreatenedorremovedaspartofdisciplinaryactionsastheyareimportanttothechild’sresilienceandwell-being.
Usecreativityandtheuniqueneedsanddesiresofeachindividualwhendevelopingthisportionofthetreatmentplan.Developingideasformanagingstressandenjoyingactivitiesispartoftreatment,sothechildoryouth’sengagementisvital.
FormalServices
Dependingupontheneedsofthechildandtheavailabilityofservicesinthecommunity,thetreatmentteammightconsiderthefollowing:MedicationSupportServices;oneofthemanytypesoftherapy,suchasindividual,family,orgrouptherapy;medicalcasemanagement,therapeuticbehavioralservices;wraparoundservices;intensivedaytreatment;orresidentialcare.Alldecisionsshouldprioritizetheneedsofthechildabovewhatismerelyconvenient.Aclearlinetothegoalsofthetreatmentplanshouldbeevidentinanyinterventionselected.TheAmericanAcademyofPediatricspartnerswithPracticeWisetocreateayearlylistofevidence-basedpsychosocialinterventions.Theyranktheinterventionsbasedonthequalityoftheresearchevidencethatsupportstheireffectiveness.Mentalhealthinterventionsmightbeincorporatedintoatreatmentplanwithorwithoutaccompanyingmedication.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 25
CountyMentalHealthPlansContactList
CountyMentalHealthPlan PhoneNumber(s)
Alameda(andCityofBerkeley) (800)491-9099
Alpine (800)318-8212
Amador (888)310-6555
Butte (800)334-6622
Calaveras (800)499-3030
Colusa (888)793-6580
ContraCosta (888)678-7277
DelNorte (888)446-4408
ElDorado (800)929-1955
Fresno (800)654-3937
Glenn (800)507-3530
Humboldt (888)849-5728
Imperial (800)817-5292
Inyo (800)841-5011
Kern (800)991-5272
Kings (800)655-2553
Lake (800)900-2075
Lassen (888)530-8688
LosAngeles–TriCity (800)854-7771
Madera (888)275-9779
Marin (888)818-1115
Mariposa (888)549-6741
Mendocino (800)555-5906
Merced (888)334-0163
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 26
CountyMentalHealthPlan PhoneNumber(s)
Modoc (800)699-4880
Mono (800)687-1101
Monterey (888)258-6029
Napa (800)648-8650
Nevada (888)801-1437
Orange (800)723-8641
Placer (888)886-5401mainline
(866)293-1940
Plumas (800)757-7898
Riverside (800)706-7500
Sacramento (888)881-4881
SanBenito (888)636-4020
SanBernardino (888)743-1478
SanDiego (888)724-7240
SanFrancisco (888)246-3333
SanJoaquin (888)468-9370
SanLuisObispo (800)838-1381
SanMateo (800)686-0101
SantaBarbara (888)868-1649
SantaClara (800)704-0900
SantaCruz (800)952-2335
Shasta (888)385-5201
Sierra (877)-332-2754
Siskiyou (800)842-8979
Solano (800)547-0495
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 27
CountyMentalHealthPlan PhoneNumber(s)
Sonoma (800)870-8786
Stanislaus (888)376-6246
Sutter/Yuba (888)923-3800
Tehama (800)240-3208
Trinity (888)624-5820
Tulare (800)320-1616
Tuolumne (800)630-1130
Ventura (866)998-2243
Yolo (888)965-6647
SupplementalMaterials:
• MentalHealth&SubstanceUseDisorderServicesInformationNoticeNo.16-063:SubstanceUseDisorder(SUD)TreatmentServicesforYouthinCalifornia
• MentalHealth&SubstanceUseDisorderServicesInformationNoticeNo.16-061:ClarificationonMentalHealthPlanResponsibilityforProvidingMedi-CalSpecialtyMentalHealthServices
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 28
Mental/BehavioralHealthServicesBrainstormingFormCountyorAgency:
RoleinMental/BehavioralHealthforfosterchildren:
CountyMHPProvider’sNameandContactInfo:OtherUsefulPartners’NamesandContactInfo:Agencystrengthsandresources:
Strengthsandresourcesoutsidetheagency:
Whatgaps/needsareleftafterconsideringthesestrengthsandresources?
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 29
Whatinformaltreatmentoptionsareavailabletochildrenandyouthservedbyyouragency?
Aretheseoptionsculturallysensitive?Safeforpotentiallytraumatizedchildren?Diverse?
Whatinformaltreatmentoptionsdoyouwishyouhadaccesstoforyourchildrenandyouth?
Whatformaltreatmentoptionsareavailabletochildrenandyouthservedbyyouragency?
Aretheseoptionsculturallysensitive?Trauma-informed?Diverse?
Whatformaltreatmentoptionsdoyouwishyouhadaccesstoforyourchildrenandyouth?
Whatcanyoudotoincreasethequalityanddiversityoftreatmentoptions?Whocanyouasktohelpdevelopneededresources/services?Canyoupartnerwithanotheragency/entityalreadyengagedinthiswork?Whatisyournextstep?
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 30
Segment6:PsychotropicMedication
FosterYouthMentalHealthBillofRights1. Fosteryouthhavetherighttoreceivementalhealthservicesandsupports.2. Fosteryouthhavetherighttoreceiveinformationabouttheirmentalhealth,includingtheirdiagnosisand
availabletreatmentoptions,inawaythatiseasytounderstandandageappropriate.3. Fosteryouthhavetherighttoparticipateindecisionsmadeaboutwhatmentalhealthtreatments,services,
andmedicationstheyreceive.4. Fosteryouthhavetherighttoreceiveneededmentalhealthservicesandsupportsinatimelyfashion.5. Fosteryouthhavetherighttoreceivementalhealthservicesandsupportsintheleastrestrictiveenvironment
appropriatetomeettheirindividualneeds.6. Fosteryouthwhoaretwelveorolderhavetherighttoprivatelyseekandconsenttooutpatientmentalhealth
counselingandtreatment(exceptforpsychotropicmedications).7. Fosteryouthhavetherighttotakeonlymedicationorotherchemicalsubstancesthatareauthorizedbya
doctor.8. Fosteryouthhavetherighttobeinformedabouttherisksandbenefitsofpsychotropicmedicationsinanage
appropriatemanner.9. Fosteryouthhavetherighttotelltheirdoctorthattheydisagreewithanyrecommendationtoprescribe
psychotropicmedication.10. Fosteryouthhavetherighttogotothejudgeandsaytheydisagreewithanyrecommendationtoprescribe
psychotropicmedications.(Fosteryouthareencouragedtotalktotheirattorneyfirsttomakesuretheyouthdoesnotsaysomethingagainsthisorherinterests.)
11. Fosteryouthhavetherighttoaskformentalhealthservices,includingre-assessmentsregardingtheirdiagnosesandtheirprescriptionsforpsychotropicmedications.
12. Fosteryouthhavetherighttoworkwiththeirprescribingdoctorinordertosafelystoptakingpsychotropicmedications.
12. Fosteryouthhavetherighttobeabletocontacttheirmentalhealthtreatmentproviders.13. Fosteryouthwhoaretwelveorolderhavetherighttoconfidentialitywhenspeakingwiththeirtherapistor
doctor.Withafewlimitedexceptions,ahealthcareprovidermustgetpermissionfromafosteryouthwhoistwelveorolderbeforesharingconfidentialmedicalinformationwithothers.(Fosteryouthareencouragedtoasktheirtherapistordoctorwhatinformationwillorwillnotbekeptconfidentialandwhotheproviderisallowedtosharetheinformationwith.)
14. Fosteryouthhavearighttokeeptheirmedicalinformationanddiagnosesconfidentialandonlysharedwiththoseauthorizedtoknowthisinformationforthepurposesofarrangingfor,coordinating,andprovidinghealthcareservicesandmedicaltreatmenttotheyouth.
15. Fosteryouthhavetherighttoseeandgetacopyoftheircourtrecord.16. Fosteryouthwhoaretwelveorolderhavetherighttoseeandgetacopyoftheirmedicalandmentalhealth
records.(Afosteryouthcanrequesthisorhermentalhealthrecords,butifahealthcareproviderdeterminesthatseeingtheserecordswouldbeharmfultothefosteryouth,theycanrefusehisorherrequest.)
17. Fosteryouthhavetherighttocontinuereceivingmentalhealthtreatmentwhentheirplacementchanges,includingwhentheyaremovedtoadifferentcounty.
18. Fosteryouthwhoareinfostercareontheir18thbirthdayhavetherighttocontinuetoreceivehealthcare,includingmentalhealthservices,throughMedi-Caluntilage26regardlessoftheirincomelevel.
ThecompleteFosterYouthMentalHealthBillofRightsdocumentwithendnotesandbestpracticesisprovidedwiththesupplementalmaterialsinthisbinder.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 31
Psychotropicmedicationinfostercare
• Non-pharmacologicalinterventionsarefirst-linetreatmentapproach.Medicationistobeconsideredonlywhenotheroptionsarenotsufficient(outsideofemergencies).
• Medicationcanbeprescribedafterthoroughassessmentidentifiesneedandcleartreatmentgoals.Keepinmindthatitmaytakemorethanonemeeting/session/cliniciantoconductathoroughassessment.
• Whennecessary,medicationisbestused:o withothersupportiveinterventionsando aspartofacomprehensivetreatmentplan
• Respectforthedignityofthechildandfamilyisaprerequisiteforalltreatment.Sciencehasyettofullydeterminetheeffectsthatpsychotropicmedicationmighthaveonthedevelopingbrainsandbodiesofchildrenandyouth,butitisclearthatsomesideeffectscanbequiteseriousandlong-lasting(Gleason,Gordon,&Yogman,2016).Consequently,thedecisiontousepsychotropicmedicationshouldbeconsideredverycarefully.Dependinguponthesymptomsachildisexperiencing,therearethreegeneralpathsforusingmedicationoutsideofemergencies:1. Medicationmightnotbeusedatallintheexampleoflearneddefianceorifsymptomsaredeterminedto
betheresultoftraumaratherthanmentalillness.2. Theteammaydecidetoincludemedicationafterotherinterventionsweretriedbutfailedtoaddressall
thesymptoms.Moderateanxietyordepressionmightbeanexampleofthisscenario.3. Medicationmaybepartofaninitialtreatmentplan,forexample,ifthechildwereexperiencingsevere
AttentionDeficitHyperactivityDisorder,acutesymptomsofdepression,orpsychosis.Ifthephysicianandchildandfamilyhavedecidedthatmedicationisnecessary,itshouldbeusedinconjunctionwithotherinterventionstosupporttheholistichealthofthechildexceptinrareemergencysituations.Incertaincases,psychosocialinterventionsarenolongerrequiredwhentheyhavealreadybeensuccessfullyemployed,butcontinuingmedicationisneededtopreventrecurrenceofsymptoms.Regardlessofwhattreatmentplanisdesigned,respectforthedignityofthechildandfamilyisaprerequisite.Alltreatmentplansshouldincludetheinputandconsentofthechildandfamily,identifyandutilizetheirstrengths,aimtoincreasetheirresilience,andprioritizetheirneeds.
Informedconsentformedication
• Expectationsareclearlyoutlinedonpg.11oftheGuidelines.
• Childrenandyoutharetobeincludedintheconsentandassentprocesstotheextentfeasiblebasedontheirdevelopmentalstage.
• Child,family,andcaregiverareinformedoftherisksandpotentialbenefitsof:
ü Proposedmedication(name,dose,effects),and
ü Alternativetreatmentsincludingtheabsenceoftreatment.
• Thoroughdiscussionofanyseriousadverseeffectstowatchforandwhenandhowtocontacttheprescriberifanythinghappens.
• PrescribersconsultwithSW/POaboutwhocanprovidelegalconsent,andreleaseofHIPAAinformation.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 32
Limitsofmedicationinfostercare
ContinuumofCareReformTitle22makesitclearthatpsychotropicmedicationsshouldnotbeusedforthepurposesofdisciplineorchemicalrestraint.Inacutepsychiatricemergencies,chemicalrestraintmaybenecessary.Thisshouldbeextremelyrare,andveryshort-term.Additionally,youtharenottobecoercedintotakingmedicationasaconditionofgettingintoorstayinginafostercareplacement.Safeandconsistentadministrationofmedicineattheprescribedtime,frequencyanddosageisasafetyissue,andmustbeaddressedinthetreatmentplan.Ifsafeadministrationcannotbeachieved,theCourtshouldbeinformed,andmedicationshouldbereconsidereduntilsafetyconcernshavebeenaddressed.Safeandaccurateself-administrationofmedicationisideal.Ifitisnotpossibleforthechildoryouthtoadministertheirmedsthemselves,itisnecessarytoassistthem.Whenassistingachildoryouthwithadministrationofmedication,itisimportanttoconsidertheirpreferencesregardinghowandwhenheorshewouldliketotakethemedicineaslongasthosepreferencesareinlinewiththeprescriber’sinstructions.Assistonlyonechildatatimeoutsidethepresenceofotherchildren.Thishelpsprotecttheirprivacyandconfidentialityaswellaspotentiallyreducingstigmaandshamethatmayaccompanytakingmedication.Documenttheappropriateprocedureforadministrationandeveryoccurrenceinthechild’srecordincludingdate,time,anddose.
AssistingwithSelf-Administration
Self-administrationofmedicationistheidealtreatmentplan.Itensuresresponsibilityandownershipoftheprocessandcanhelpempoweryoungpeople.Sometimesthiswillbeasimpleprocess;forotheryouth,itmaybemoreofachallenge.Herearesomeideasthatmayhelp--
Makesurethattheyoungpersonyouareassistingisawareofandthoroughlyunderstandstheprescriber’sinstructionandhowtogetadditionalinformationifthereisconfusion.Goovertheplanthoroughlyandmakeparticularnoteoftheanticipatedeffects,bothpositive¾suchassymptomrelief¾andpotentiallynegative¾likesideeffects.
Regularlyreiteratetheimportanceoftakingthemedicationaccordingtotheinstructions.Itisnotenoughtosaythisonceatthebeginning.Itisimportanttoreinforcethismessagethroughoutthecourseoftreatment.Inparticular,makesuretheyouthunderstandsthatitcouldbequitedangeroustomissdosesorstoptakingmedicationwithoutthesupportofadoctor.Also,explainthattheywon’tbeabletotellifthemedicationisworkingornotunlesstheytakeitasinstructed,andthattheymaynotgetanybenefitfromthemedicationatallifitisn’ttakencorrectly.
Storethemedicationinasecurelocationthattheyouthcanaccesswhentheyneedto.Thereareobvioussafetyconsiderationstofactorindependinguponthesituation,theyouth,andthemedication.Strivetoachievethemostaccessibleandempoweringsituationfortheyouthwhilecontinuingtoensurethesafetyofeveryone.Itisimportanttokeeptrackofmedicationandtobeawarewhenrefillsarecomingup.TheCommunityCareLicensingDivisionhasspecificguidelinesforgrouphomesandotherfacilitiesregardingmedicationthatcanbefoundintheSupplementalMaterialssectionofthissegment.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 33
Becreativeaboutsupportingyouthtostayonschedule.Colorfulcalendarsorpillboxescanhelpmaketheprocessseemlessdullorclinical.Iftheyouthisusingacellphoneorcomputeranyway,somehelpfultoolscansupporttheirself-administration.Forexample,MangoHealthisamedication-trackingappthatisdesignedlikeagame.Participantscanearnpointsforstickingtotheirschedule,andtheycanevenwinreal-worldprizes,likegiftcards,forreachingtheirgoals.MedHelperandMedCoacharetwoothermedication-trackingappsthatmighthelpkeepyouthontrackandprovidetheircaregiveranddoctorwithinformationabouthowtheyaredoing.Someyouthmayevenwanttokeeptrackoftheirsymptomsandsideeffectsusingthenotesfunctionwithintheappitself.Whensymptomsimproveandthechildisfeelingbetter,itcanbeparticularlychallengingtokeeptakingmedication.Itisveryimportantthatthetreatmentteamandthecaregiverhaveregularlyscheduledcheck-insaboutsymptomsandmedication.Youngpeopleneedsupportthroughoutthecourseoftreatment,notonlywhenthingsaredifficult.Itisimportanttolistencarefullytowhattheysayabouthowtheyfeelandwhattheywantwhenitcomestotheirownhealthcare.Youngpeopledon’talwaysknowwhatisbestforthem,buttheyarealwaystheexpertsinhowtheyfeel.Buildingatreatmentplanthatwillworkbestforeachspecificpersonrequiresthattheybepartoftheplan.Everypersonisunique,soremainopentoalltheoptions.Continueaskingquestionsandexploringuntilyoufindtherightfit.Finally,scheduleregularcheck-inswiththeyouthandmembersoftheteamabouttreatmentandsymptoms.Anddiscussallchanges,notjustthetargetsymptoms.Bereliableandconsistent.
Risks
Psychotropicmedicationsareassociatedwithanarrayofpossiblerisks.Theyvarywidelydependingupontheageanduniquecharacteristicsofindividualswhotakethem.Someoftheserisksarecalledsideeffects,meaningthatmedicationcancauseeffectsotherthanorinadditiontotheintendedones.
Individualshaveexperiencedincreasedsuicidalideation,sleepdisturbance,sleepinessandlethargyordifficultymovingaround.Somehaveexperiencedrapidweightgainleadingtoobesityandpronouncedchangesintheirbloodsugarandmetabolismsometimesleadingtodiabetes.Nervousness,restlessness,andirritabilityarealsocommoncomplaints.Headachesandupsetstomachorchangesinappetitearealsopossible.Alltheserisksshouldbemadecleartothechildandfamilywhentreatmentdecisionsarediscussed.Childrenandfamiliescannotmakeinformeddecisionswithoutbeingawareofthesepotentialrisks.TheCaliforniaGuidelinesdirecttheprescribingphysiciantoinformthechild,family,andothersinvolvedintreatmentplanningabouttherisksandbenefitsofthemedicineandofothertreatmentoptionsincludingtherisksandbenefitsofnotreatment.Rarely,individualsmayhaveadversereactionsthatcauseseriousillnessordeath.Chronicillnessandpermanentfacialorbodyticsandtremorsdosometimesoccur.Itispossibleforchildrenoryouthtobecomeaddictedtocertainmedications,andthisriskshouldbeincludedindecisionmaking.Additionalrisksarepresentwhenmedicationsarenottakenaccordingtotheinstructions.Treatmentplansshouldincludedetailsaboutsafeandconsistentadministrationofthemedication,ensuringanadequatesupplyofmedication,andasafetyplanforhowtostoptakingthemedicationshouldthatbenecessary.
Thereareappsthatcanhelpwithself-administeringmedication:
• MangoHealth• MedHelper• MedCoach
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 34
SubstanceUseandMedication
Carefulconsiderationofthechild’soverallhealthandneedsiscrucialtocreatinganeffectivetreatmentplan.Ifthechildoryouthusesun-prescribedmedications,otherdrugs,oralcohol,itisimportanttoassesstheriskofaddingapsychotropicmedication.Interactionsbetweenmedicationsanddrugsoralcoholcanbepowerfulandtoxic.Sometimes,individualsareusingdrugsoralcoholtoself-medicateandtoessentiallytreatthesamesymptomsthatthetreatmentplanisattemptingtoaddress.
Alternatively,substanceusedisorderitselfcanmimicthesignsorsymptomsofotherdysregulations.Ifthatisthecase,thatdisordermustbetreatedfirstinordertoaccuratelydiagnosisthechildoryouth.Ifbothsubstanceusedisorderandotherbehavioralhealthissuesarepresent,dualdiagnosistreatmentshouldbeprioritizedinthetreatmentplan.Thismeanstreatmentthatfocusesontheintersectionandoverlapofproblematicsubstanceuseandseriousmentalhealthneeds.
Potentialbenefits
Thebesttreatmentplanforanindividualmayincorporatemedication,whichhasthepotentialtoimproveschoolperformanceandabilitytoconcentrate,decreasetheexperienceofanxietyorworry,reducesymptomsofdepression,improveoreliminatefrequentphysicalpainorsomaticcomplaints,reduceoreliminatenightmaresandothersleepdisturbance,andlimitexcessiveaggressionortempertantrumsandimprovemood.Thesepotentialbenefitsaretobeweighedagainstthepotentialriskswhendecidingwhetherornottoincludemedicationinachildoryouth’streatmentplan.Forchildrenandyouthinfostercare,notallofthesepotentialbenefitsarefullybackedbyevidence(AmericanAcademyofPediatrics,xxx).Therefore,itisvitalthattheintroductionofmedicationsisincremental;beginningwithalowdose,andslowlyadjustedwhilecarefullytrackinganypositiveornegativeeffects.Itisimportanttonotethatallthebenefitsdescribedherearealsopotentiallyachievablewithouttheuseofpsychotropicmedicationdependingontheindividual.Caremustbetakentorefrainfromviewingpharmaceuticalsastheonlyoptionorasacure-allforeveryone.
AttentionDeficitandAnxiety/DepressionMedications
AttentionDeficitandHyperactivityDisorderorADHD:Arelativelycommondiagnosisforchildrenandyouth.PsychomotorstimulantslikeRitalinandAdderallareoftenprescribedtotreatthesymptomsofADHD.Theycanhelpchildrentoconcentrateandcontrolhyperactivity.Commonsideeffectsincludedecreasedappetiteorstomachdiscomfortandpoorsleep.Non-stimulantssuchasStratterahavethesamebenefitsaswellasdecreasedcompulsivebehaviors.Thecommonsideeffectsarealsosimilar—stomachdiscomfortandpoorsleepalongwithheadache.
AnxietyandDepression:Symptomsrelatedtoanxietyanddepressionmayalsobeaddressedwithmedication.SelectiveSerotoninReuptakeInhibitorsandAtypicalAntidepressantssuchasProzac,Zoloft,Celexa,WellbutrinorLexapromaydecreasedepressivesymptoms,improvemood,anddecreaseanxiety.Theycancausenausea,anddisturbsleep.Theyalsoposeanincreasedriskofseizureandanincreasedriskofsuicidalideationespeciallyinadolescents.Thesesideeffectsmayincreasewithirregularadministration,soshouldbecarefullyconsideredifproperadministrationisdifficultorunlikely.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 35
MoodandPsychoticDisorderMedications
Mooddisorders:ToaddressthesymptomsofmooddisorderssuchasBipolarDisorder,doctorsprescribemoodstabilizerslikeLithiumorAnticonvulsantslikeDepakote.Thesemedicationsmayimproveorstabilizemoodsymptomsandimproveimpulsecontrol.Lithiumcancausedrymouth,tremor,stomachdiscomfort,weightgain,memoryproblems,thyroidandkidneyproblems.Anticonvulsantsalsohaveseriouspotentialsideeffectssuchasdrowsiness,nausea,seriousrashes,liverproblems.Periodiclabtestsandcarefulmonitoringbyaphysicianisnecessarywhilechildrenoryoutharetakingthesemedications.
Psychoticdisorders:Antipsychoticmedicationsareapotentclassofpsychotropicmedications.Theyaredividedintotwocategories,NewerandOlder.Theyareusedtotreatveryserioussymptomssuchashallucination,delusions,anddisorderedthinking.Theycancauseextrapyramidalsideeffects(EPS)suchasshakiness,drooling,andstiffness.Theyoftencauserapidweightgain,heartandbloodirregularities,permanentticsandtremors,anddiabetes.
Medicationstoaddresssideeffects
Manypsychotropicmedicationshavethepotentialtocausesleepdisturbance.Doctorsmayprescribesedativesorhypnotics,andsometimessleep-promotingmedicationslikeBenadryltohelpchildrensleep.Thesemedicationshavethepotentialtobehabit-formingandcancauseadditionalsideeffects.
Theseveresideeffectsfromantipsychoticscanbetreatedwithanticholinergicmedications.Thesecanreducetheshakiness,drooling,andstiffnessassociatedwithEPS.
Itisimportanttonotethatmultiplemedicationsandusingmedicationtotreatsideeffectsofothermedicationisnotrecommendedpractice,butdoesoccur.Childrenwithseveralsimultaneousprescriptionsareatincreasedriskforadverseeffects.Useofmultiplemedicationsshouldbecarefullymonitoredbythefamilyandthephysician.Aswithallmedication,thesedecisionsshouldbecarefullyanalyzedbytheentiretreatmentteamtoensurebestoutcomesforthechild.
SideEffects
Safety:Ifsideeffectsaresuspectedoridentified,safetyisthepriority.Followallemergencymedicalproceduresifnecessary,andtakenecessarystepstoensurethesafetyofthechild.
• Consultwiththeprescribingphysicianimmediatelytodetermineifchangesneedtobemade.• Donotallowthechild/youthtosimplystoptakingmedication.Thereisusuallyaprotocolforweaning
offpsychotropicmedications,anditisvitaltofollowthosedirections.• Ifdoseorschedulechanges,followupwiththerequiredCourtdocumentsanddocumentthechange
inthehealthrecordandthechild’sfile.
Planahead:Findoutwhatsideeffectsarepossiblewhenthetreatmentplanwithmedicationismade.Haveasafetyplancreatedintheeventthatsideeffectsemerge.Itisimportanttobeawareifthereareanyknowninteractionswithotherdrugsoralcoholaswellasstepstotakethatmightreducethelikelihoodofsideeffects.
• AppendixBoftheCAGuidelinesistheprimarydocumentCDSShasidentifiedforreferenceaboutspecificmedicationsandtheparametersfortheiruse(dosage,sideeffects,potentialinteractions,etc.)LACountyiskeepingthisdocumentup-to-dateandpubliclyavailableontheirwebsite.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 36
• Youcanlearnmoreaboutpossiblesideeffectsbyresearchingonsiteslikemedlineplus.govorfindingthepackageinsertfortheprescribedmedication,whichareusuallyavailableonline.
DocumentingSideEffects
• Socialworkersandprobationofficersmustensurethatmonitoringoccurs.ItmaybethePHNorcaregiverwhodospecifictasks,butthesocialworkerisresponsibleformakingsureithappensasoftenandthoroughlyasnecessary.
• Socialworkersandprobationofficersdon’tneedtobetheexpertsinknowingallthedetailsofthisinformation,buttheymustcollectitfromthedoctorsandhealthprofessionalswhoareexpertsandmakesurethatthechildandcaregiverandfamilyhavereceivedtheinformationandunderstandit.
• Regularlyaskthechildoryouthtodescribetheirexperiences—bothphysicalandemotional—sincetakingthemedication.Askthemtocomparethoseexperiencestohowtheyfeltbeforetakingmedication.Thisassessmentshouldoccurthroughoutthedurationofthetreatmentassideeffectscandevelopatanytime.
• Ifdevelopmentallyappropriate,thechildshouldbeawareofeffectstowatchoutforandwhotheyshouldtelliftheyexperiencesomethingnew.
• Theprescribingphysicianshouldmakecleartothetreatmentteamhowtheycanbecontactedshouldsomethingarise.
• Therecommendeddoseshouldbeageappropriate.ThismaybedifficulttodetermineastheFDAhasnotapprovedmanyofthecommonpsychotropicmedicationsforusewithchildrenoryouth.
• AppendixAoftheCaliforniaGuidelineshasageparameters.Evenifthedosefallswithinacceptableguidelines,itmaybetoomuchortoolittleforaspecificindividual,soitisimportanttomonitortheirresponses.
• Itisalsoimportanttocheckwiththefamilyandcaregiversofthechildoryouthtoseewhethertheyhavenoticedanychangesinthechild’smood,behaviororappearance.Schoolpersonnel,friendsfromchurchandthecommunitymayalsobeabletoidentifyiftherearechangesinthechild’sbehaviorintheseotherenvironments.
• Collectivevigilanceandfrequentcommunicationcanhelpidentifyandaddresssideeffectsfrompsychotropicmedications.
SupplementalMaterials:
• FosterYouthMentalHealthBillofRights• QuestionstoAskAboutMedicationsBrochure• AlamedaCountyTransition-AgeYouthSideEffectInformationalCards• AmericanAcademyofChildandAdolescentPsychiatry—FactsforFamilies:WeightGainfrom
Medication,PreventionandManagement• MedicationMonitoringChecklist• CommunityCareandLicensingResourceGuidetoMedicationsinGroupHomes• SampleSafetyPlan
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 37
Activity:QuickRolePlay
1. Six-year-oldElizabethhasrecentlybeenprescribedRitalintoaddressrestlessness.Hertreatmentplancallsforevaluationofsymptomsandsideeffects.
2. Juliusis17yearsoldandabouttotransitionoutoffostercare.HecurrentlytakesaSelectiveSerotoninReuptakeInhibitor(Celexa)foracuteanxiety.Hisfostermotherisconcernedthathewillstoptakingitonceheleavesherhome,andwouldlikehimtohaveasafetyplan.
3. Afterherappointmentwiththedoctor,Phoebehassomequestionsabouttherisksandbenefitsoftakingtheantipsychotic(Zyprexa)thatherdoctorisrequestingfromthecourttoaddressherimpulsivityandaggression.Sheis15yearsoldandlivesinagrouphome.
4. CharlotteistenyearsoldandshehasbeentoseehertherapistweeklyforthreemonthsandistakingVistariltohelphersleep.Shefeelsthathersleepisbetter,butthetherapyismakingthingsworse,andtheconversationsshehasmakehermoreupset.Shewantstostopgoing.
5. Derrickisafosterparent.Hewastoldbythedoctorathisfosterson’slatestappointmentthatAdderalldoesnothaveanysideeffects.Hiseight-year-oldfostersonwasalreadytakingitwhenhecametoDerrick’shome.
6. TheApplicationforSamtostarttakingZolofttoaddresssymptomsofseveredepressionwasapprovedbythecourt.Discusstheriskofsuicidalideationrelatedtothisdruganddecideaboutsafetyplanning.Samis13yearsold.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 38
Segment7:UsingtheCaliforniaGuidelines
WhataretheGuidelines?
TheCaliforniaGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCareisadetaileddocumentandfourappendicesthatwerecreatedandassembledcollaborativelybyCDSSandDHCS.
• Sharedvalues,expectations,andprinciplesofpsychotropicmedicationuseinfostercare.• Designedtobeanadvocacytooltohelpguidenon-medicalprofessionalswhenworkingwithdoctors
andpsychiatristsandothermedicalpersonnelorserviceprovidersSeveralimportantgoals:
• Increasedvisibilityofstrengthsandneedsofchildrenandyouthwithemotional,cognitive,and/orbehaviordysregulation
• Reductionofsocialstigmaduetodysregulation• Promotingbestpracticesinthestate’scommitmenttoprovidebothformalandinformal
mental/behavioralhealthservicestochildrenandyouthincare.Outlinesexpectationsabout:
• Treatmentplans,assessment,anddiagnosis• Whatprescribersshouldconsiderforcertainactivities
o Beforeprescribingo Whenprescribingo Whenevaluatingwhetherornotatreatmentiseffectiveo Prescribinginanemergency
FourAppendiceswithtools:A:PrescribingStandardsbyAgeGroupB:Parametersfordoserangeandschedule(LACounty’sParameters3.8)C:ChallengesinDiagnosisandPrescribingincludingrecommendationsD:DecisionTreeforPrescribing
PrinciplesandValues
TheGuidelinesoutlinethesharedprinciplesandvaluesofCDSSandDHCSregardingtheuseofpsychotropicmedicationwithchildrenandyouthinfostercare.
• Alwaystopromotesafety,permanence,andwell-being• Realpartnershipswiththeimportantpeopleinthechild’slife• Workingfromachild-centered,strength-basedperspectivetocreatetrulyindividualizedtreatment• Providingthehighestqualityofcarethatisintegratedwithinthechild’scommunityandin
collaborationwithanyhelpfulpartners.• Psychotropicmedicationisnottobeemployedasthesoleintervention(exceptinextremelyrare
caseswhentreatmentwithmedicationissuccessful,butneedstobecontinued),butratheraspartofarobustoveralltreatmentstrategyemployingbothformalandinformalinterventions.
TreatmentPlan
Atreatmentplanisthedetaileddescriptionofservices,supports,andtreatmentsthatwillbeemployedtoeliminateorreducethechildoryouth’sidentifiedsymptoms,emotionaldistress,and/orproblematic
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 39
behaviors.Itisthedocumentthatdescribeshowtheteamwillattempttoimprovethingsforthechild.Treatmentplanningisalwaysdonecollaborativelywithchildrenandtheirfamilies,whetherornotaChildandFamilyTeamiscreated.Amulti-disciplinaryteamfunctionsverysimilarly,oranevenless-structuredsupportivegroupcanbesuccessfulincreatingaqualitytreatmentplan.Theimportantthingistoincorporatediverseperspectivesthatbuildaroundtheuniqueresources,abilities,strengths,andneedsofeachspecificchildandhisorhernaturalsupportnetworkandcommunity.Ifachildistooyoung,oriftherearedevelopmentalorprotectiveissuesinthecasethatpreventcollaboration,everyeffortshouldbemadetoinvolvearepresentativetospeakonbehalfofthechildindecisionmakingmeetings.Toeveryextentpossible,thechildortheirrepresentativeshouldbeincludedinalltheplanning,review,andre-assessmentofthetreatmentplan.AccordingtothebestpracticeoutlinedintheGuidelines,treatmentplansincludethefollowing:• Thechild’sdiagnosisand/oroutlineofemotional/cognitive/behavioraldysregulationbasedonthechild’s
historyofabuse,neglect,and/orremovalfromthehome;• Adescriptionofthechild’sbaselinestrengthsandneeds;• Targetsymptomsasagreedtobythechild,family,andteammembersandexpressedinclear,everyday
language;• Short-andlong-termtreatmentgoals;• Interventions,includingevidence-supportedtreatments,psychosocialinterventions,substanceabuse
preventionortreatment,casemanagement,informalmentalhealthservices,educationalorbehavioralservices,extracurricularandrecreationalactivitieswithstartdatesandanticipatedduration;and
• Aclearandspecificplanforperiodicreviewandreassessment.KatieA.plansmustbereviewedatleastevery90days.
• UpdatedmedicationtreatmentplansmustbecommunicatedasanattachmenttotheJV220formforthecourt,aswellassharedwiththechild/youth,family,caregiver,andchildwelfaresocialworkerand/orprobationofficerfordistributiontoallnecessarypartiesinaccordancewithHIPAA.
Thesearethebasicsofhigh-qualitytreatmentplanning.Plansshouldseektoutilizeavarietyofinterventionstoaddresstherootcausesofdysregulationwhetherthatcauseistraumaormentalillnessoracomplexinteractionofmultiplefactors.Alleviationofspecificsymptomsisimportant,butisonlyPARTofacomprehensivetreatmentplan.Includinginterventionsthatarebackedbyevidenceiscrucial.Plansshouldseektobecomprehensiveandtreatthewholechildnotsimplytheperceived“problems”withthechild’sbehaviororfunctioning.HIPAAcomplianceisasimportantintreatmentplanningasitisinallareasofhealthcare.
NeedsAssessment
Childrenwhohaveemotional,cognitive,and/orbehavioraldysregulationfromtrauma,mentalhealthconcerns,orforotherreasonsrequireanddeserveatreatmentplanthatcontainsavarietyofinterventionstoalleviatetheirsymptomsandtopromotetheirsafetyandwell-being.Thefirststepinthatprocess,isahigh-quality,trauma-informed,child-centeredassessment.
Aswementionedbefore,anyassessmentofchildrenoryouthinfostercareshouldbeconductedbyalicensedpractitionerwhoisinformedabouttheconditionsandeffectsoftrauma.Andshouldthoroughlycoveralloftheseitems:
• PhysicalANDmentalstatusexaminations,
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 40
• Identificationoftargetsymptomsandthegoalsoftreatment,• Aclearplanandtimelineforre-assessmentandhowmonitoringprogresswilloccurandwhois
responsibleforwhichpartsoftheplan,and• Aclearrisk/benefitanalysisofeachtreatmentintheplanincludingtherisksandbenefitsofno
treatment
PhysicalExamination
Theresultsofthemostrecentphysicalexaminationofthechild—withinthepastyear—shouldbereviewedaspartofthetreatmentplanningprocess.Theseresultswillbeusedtoruleoutmedicalconditionswhentheymaycontributetoorcausethepresentingsymptoms,andtoprovidebaselineinformationformonitoringpotentialsideeffects.Asappropriate,thetreatmentteammayconsiderapregnancytestorsubstanceusescreen,asbothcouldhaveseriousimplicationsforwhetherornottoprescribepsychotropicmedication.Theseinitialexaminationsareparticularlyimportantforfollow-upandmonitoringsideeffectsbecausewithoutabaseline,itmaytakelongertonoticechangesthatmayindicatedangerousdevelopmentsorsideeffectsthatneedtobeaddressedquickly.
MentalHealthExamination
Theexaminationofthechild’smentalstatusshouldbedevelopmentallyappropriate.Anyapplicablediagnosisshouldbeinlinewithprofessionalstandardsandbesupportedbysufficientdocumentationtoruleoutotherpossiblediagnoses.Theassessmentshouldidentifythetargetsymptomsandgoalsoftheselectedtreatment,alongwithatimelineforwhenresultsshouldbeexpectedandhowlongthetreatmentisintendedtolast.Itisimportanttosharetheresultsofthisassessmentwiththechildandtheirsupportnetwork,butitisespeciallyimportanttosharethegoalsandtargetsymptomswiththem.Inthisway,everyonewillunderstandwhatthetreatmentisforandwhattoexpect.Itisalsoimportanttoconsiderifthegoalsarefocusedontreatingtheunderlyingemotionaldistressthatthechildisexperiencing,andtorefocusthemontoalleviatingthatdistressifnecessary.Regularre-assessmentisanexpectedactivity.Thetreatmentteamshouldmonitorsymptoms,sideeffects,andthechildandfamily’sneedsanddesires.Alltreatmentplansshouldexplicitlyincorporatearisk–benefitanalysisthatcomparesatreatmentplanwithoutmedicationtothepotentialbenefitsandrisksofaddingaprescription.
GoalsandTargetSymptoms
Tremendouslyimportanttothequalityofthetreatmentplanistoidentifyspecificsymptomsthatthetreatmentisintendedtoaddress.Thisiswherethevoiceandopinionofthechildiscrucial.Treatmentplansshouldnotjusttargetthebehaviorsthatacaregiverfindsproblematic,butattempttoaddressthecoreissuesandsourceofdysregulation.Ideally,NOTjustmedicationwillbeusedtoreachthegoalsstatedhere.
InformedConsent
Itisimportanttoobtaininformedconsentforanyandalltreatment,notjustformedication.Theroleofthesocialworker,publichealthnurse,and/orprobationofficeristoensurethatthechildunderstandstheirrightsandtherisks/benefitsoftheproposedplan.Useterminologythatisclearandeasytounderstand.Informationshouldbeprovidedinthechildandfamily’sprimarylanguageandinwrittenform,ifpossible.InCalifornia,achildtheageof12andoverhastherighttoconsenttotreatmentandtherighttorefuseconsent.Theassent,oragreement,ofchildrenyoungerthan12isveryimportant.Thesocialworkerisresponsibleforknowingwhoisandwhoisnotabletoprovidelegalconsent.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 41
GuidelinesforPrescribing
• StartLow,GoSlow—tobestmonitoreffectivenessandsideeffects,itisimportantthatpsychotropicmedicationsareintroducedoneatatime,andstartingfromthelowestrecommendeddose.Thedosecanbeincrementallyincreaseduntilthelowesteffectivedoseisidentified.
• On-labelUse—preferenceshouldalwaysbegiventomedicationsthatareFDAapprovedfortheagegroup,diagnosis,anddoseforwhichitisbeingprescribed.Medi-Calhasalistofbrandsandgenericsthatshouldbeusedwhenpossible.
• Ifchangesarenecessary,theyshouldbemadetoonemedicationatatime.Itisverydifficulttodeterminewhatisworkingandwhatisn’tifmultiplechangestakeplaceatonce.
• Ifyouthinktheremaybetoomuchinaprescribeddoseortoomanymedicationstotal,talktoapsychiatricspecialistatyourcounty.Donotassumethatthedoctorisright.It’sokaytogetasecondopinion.
SupplementalMaterials:
• CaliforniaGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCareandAppendices
• AllCountyInformationNoticeNo.1-0514:SharingInformationwithCaregivers• AllCountyInformationNoticeNo.1-36-15:ImprovingSafetyforChildreninFosterCareReceiving
PsychotropicMedications
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 42
Activity:GetFamiliarwiththeGuidelines
1. Whatpagewillhelpyoudeterminetheprescribingstandardsforachildwhois13yearsold?
2. WhatareallthepotentialcomplicationsandsideeffectsforSerotonergicAntidepressants?
3. AccordingtotheGuidelines,whoisresponsibleforobtaininginformedconsent?
4. Sometimesdoctorsprescribemedicationtotreatasymptomotherthanthemedication’sindicateduse.Thisiscalledofflabelorblackboxprescription.WhereintheGuidelinescanyoufindinformationaboutthechallengeofoff-labelor“blackbox”prescription?
5. WhatarethethreesectionsofthePrescribingAlgorithm(DecisionTree)?Follow-upquestion,whatisSectionCactuallyusedfor?
6. HowdotheGuidelinesdocumentsconnectwiththeJV-220process?
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 43
Segment8:WrapUpandEvaluation
WrapUpQuestions—
• IsthereanythingmissingfromtheGuidelinesthatyouthinkmighthelpyouwithpsychotropicmedicationinfostercare?
• Whataboutworkingfromatrauma-informedperspectiveresonateswithyouthemost?
• Whatdoyouneedtoincorporatethisperspectiveintoyourwork?
• Anyremainingquestions?
Ombudswoman’sOffice
Ifyouhaveanyquestionsorconcernsaboutpsychotropicmedicationinfostercare,theFosterCareOmbudswomanofCaliforniahasagreedtohavehercontactinformationincludedinthistraining.
Herofficeisavailableforsupportandresourcesonthistopic.
Toll-freephone:1.877.846.1602
E-mailaddress:[email protected]
CourseEvaluations
Thankyouforyourtimeandattentiontothisimportanttopic.
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 44
Resources
• CalSWEChostsatoolkitforthechildwelfare/mentalhealthlearningcollaborativethathasanarrayoftrainingandimplementationresourcesregardingthedeliveryofbehavioralhealthservicestochildreninfostercare.Thetoolkitalsoprovidescontactinformationforpartneringorganizationsthatprovidetrainingandtechnicalassistance.ThetoolkitwasdesignedforusebyCaliforniacountiesandregions,andisalsoaccessiblebythepublic:http://calswec.berkeley.edu/toolkits/child-welfare-mental-health-learning-collaborative-katie.Withinthistoolkit,youmayhaveparticularinterestintheresourcesfoundinthewebpagesfor“TeamingTools”and“EngagementTools.”
• TheChildren’sBureaupublishedMakingHealthyChoices:AGuideonPsychotropicMedicationsforYouthinFosterCarein2012https://www.childwelfare.gov/pubs/makinghealthychoices/andthecompanionguideforcaregiversandcaseworkerscalledSupportingYouthinFosterCareinMakingHealthyChoices:AGuideforCaregiversandCaseworkersonTrauma,Treatment,andPsychotropicMedicationin2015https://www.childwelfare.gov/pubs/mhc-caregivers.Theyarebothvaluableresourcesonthetopicsmostrelevanttothistraining.
• SubstanceAbuseandMentalHealthServicesAdministration’sConceptofTraumaandGuidanceforaTrauma-InformedApproach,July2014http://store.samhsa.gov/shin/content/SMA14-4884/SMA14-4884.pdf
• AmericanAcademyofPediatrics’HelpingFosterandAdoptiveFamiliesCopewithTrauma(2015)https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Documents/Guide.pdf
• TheNationalChildTraumaticStressNetwork’stoolkitswww.NCTSN.org
• AlamedaCountyTransition-AgeYouthandshareddecisionmakingtools:http://www.acbhcs.org/MedDir/decision_tools.htm
• http://www.dhcs.ca.gov/individuals/Pages/MHPContactList.aspx
• TheCaliforniaInstituteforBehavioralHealthSolutions(CIBHS)offerstrainingresourcesthatsupportKatieA.implementation,includingwebinarsforpreparingyouth,parents,andprofessionalsforparticipationintheChildandFamilyTeam(CFT)andteammeetings:http://www.cibhs.org/katie-implementation-technical-assistance-and-training
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 45
ReferencesAdministrationforChildren&Families,U.S.DepartmentofHealthandHumanServices,Information
Memorandum:OversightofPsychotropicMedicationforChildreninFosterCare:TitleIV-BHealthCareOversight
&CoordinationPlan,ACYF-CB-IM-12-03(April11,2012)
AmericanAcademyofChildandAdolescentPsychiatry.(January1,2009).Practiceparameterontheuseof
psychotropicmedicationinchildrenandadolescents.JournaloftheAmericanAcademyofChildandAdolescent
Psychiatry,48,9,961–73.
Breggin,P.R.(1999).PsychostimulantsinthetreatmentofchildrendiagnosedwithADHA:Part1:-Acuterisksand
psychologicaleffects.EthicalHumanSciencesandServices,Vol.1(21),13–33.
Breggin,P.R.(1999c).PsychostimulantsinthetreatmentofchildrendiagnosedwithADHD:Risksandmechanism
ofaction.InternationalJournalofRiskandSafetyinMedicine,12,3–35.Byspecialarrangement,thisreportwas
originallypublishedintwopartsbySpringerPublishingCompanyinEthicalHumanSciencesandServices(Breggin
1999a&b).
Bullard,S.,Davis,A.,Moore,S.,&Morris,D.(2013,April17).Collaborativeapproachtodecidingifandwhento
issueandmonitorpsychotropicmedication[Webinar].UCDavisExtensionforHumanServices.ArchivedWebinar.
RetrievedJune30,2015from
http://humanservices.ucdavis.edu/Resource/FamilyFocused/InThisSection/AchivedWebinars.aspx
ChadwickTrauma-InformedSystemsProject.(2012).Creatingtrauma-informedchildwelfaresystems:Aguidefor
administrators(1sted.).SanDiego,CA:ChadwickCenterforChildrenandFamilies,11.11Chadwick,49.
Crismon,M.L.,&Argo,T.(2009).Theuseofpsychotropicmedicationforchildreninfostercare.ChildWelfare,
88(1),71–100
Cohen,D.,&Sengelman,I.(2008).CriticalThinkRx:Acriticalcurriculumonpsychotropicmedications.Retrieved
July15,2015,fromwww.criticalthinkrx.org
deSá,K.(2014,August24).DruggingourKids.SanJoseMercuryNews.Availableat:
http://webspecial.mercurynews.com/druggedkids/?page=pt1
dosReis,S.,Yoon,Y.,Rubin,D.M.,Riddle,M.A.,Noll,E.,&Rothbard,A.(2011).Antipsychotictreatmentamong
youthinfostercare.Pediatrics,128(6),e1459–e1466.doi:10.1542/peds.2010–2970
Griffin,G.,McClelland,G.,Holzberg,M.,Stolbach,B.,Maj,N.,&Kisiel,C.(January01,2011).Addressingthe
ImpactofTraumabeforeDiagnosingMentalIllnessinChildWelfare.ChildWelfare,90,6,69-89.
Grimm,B.(n.d.).PsychDrugsActionCampaign.Akeyconceptforpsychotropicdrugreform:“Whatgetsmeasured
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 46
getsdone.”RetrievedJune3,2015,fromhttp://childpsychdrugsafety.org/a-key-concept-for-psychotropic-drug-
reform-what-gets-measured-gets-done
Hayek,M.,Mackie,T.I.,Mulé,C.M.,Bellonci,C.,Hyde,J.,Bakan,J.S.,&Leslie,L.K.(2013).Amulti-statestudyon
mentalhealthevaluationforchildrenenteringfostercare.AdministrationandPolicyinMentalHealthandMental
HealthServicesResearchAdmPolicyMentHealth,41(4),552–567.doi:10.1007/s10488-013-0495-3
Hughes,S.,&Cohen,D.(January1,2010).Understandingtheassessmentofpsychotropicdrugharmsinclinical
trialstoimprovesocialworkers'roleinmedicationmonitoring.SocialWork,55,2,105–15.
Leslie,L.K.,Raghavan,R.,Hurley,M.,Zhang,J.,Landsverk,J.,&Aarons,G.(2011).Investigatinggeographic
variationinuseofpsychotropicmedicationsamongyouthinchildwelfare.ChildAbuse&Amp;Neglect,35(5),333–
342.http://doi.org/10.1016/j.chiabu.2011.01.012
Longhofer,J.,Floersch,J.,&Okpych,N.(February01,2011).Fosteryouthandpsychotropictreatment:Where
next?.ChildrenandYouthServicesReview,33,2,395-404.
Mackie,T.I.,Hyde,J.,Rodday,A.M.,Dawson,E.,Lakshmikanthan,R.,Bellonci,C.,Leslie,L.K.(2011).Psychotropic
medicationoversightforyouthinfostercare:Anationalperspectiveonstatechildwelfarepolicyandpractice
guidelines.ChildrenAndYouthServicesReview,33(11),2213–2220.
http://doi.org/10.1016/j.childyouth.2011.07.003
Moses,T.,&Kirk,S.A.(January1,2006).Socialworkers’attitudesaboutpsychotropicdrugtreatmentwith
youths.SocialWork,51,3,211–22.
NationalSurveyofChildandAdolescentWell-Being,No.17:Psychotropicmedicationusebychildreninchild
welfare.(2012).PsycEXTRADataset.doi:10.1037/e565682012-001
Raghavan,R.,Lama,G.,Kohl,P.,&Hamilton,B.(2010).Interstatevariationsinpsychotropicmedicationuse
amonganationalsampleofchildreninthechildwelfaresystem.ChildMaltreatment,15(2),121–131.
http://doi.org/10.1177/1077559509360916
Raghavan,R.,Zima,B.T.,Andersen,R.M.,Leibowitz,A.A.,Schuster,M.A.,&Landsverk,J.(January01,2005).
Psychotropicmedicationuseinanationalprobabilitysampleofchildreninthechildwelfaresystem.Journalof
ChildandAdolescentPsychopharmacology,15,1,97–106.
Sheldon,G.,Berwick,D.,&Hyde,P.(2011).JointLettertoStateChildWelfare,Medicaid,andMentalHealth
AuthoritiesontheUseofPsychotropicMedicationforChildreninFosterCare.AdministrationforChildrenand
Families,CentersforMedicareandMedicaid
Services,&SubstanceAbuseandMentalHealthServicesAdministration.WashingtonD.C.Availableat:
TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 47
https://childwelfare-stage.icfwebservices.com/systemwide/mentalhealth/effectiveness/jointlettermeds.pdf;
Safer,D.J.,Rajakannan,T.,Burcu,M.,&Zito,J.M.(2015).Trendsinsubthresholdpsychiatricdiagnosesforyouth
incommunitytreatment.JAMAPsychiatry,72(1),75.doi:10.1001/jamapsychiatry.2014.1746
TexasDepartmentofFamilyandProtectiveServices(DFPS)andtheUniversityofTexasatAustinCollegeof
Pharmacy.(2013).PsychotropicMedicationUtilizationParametersforChildrenandYouthinfosterCare.
RetrievedSeptember21,2015from
https://www.dfps.state.tx.us/Child_Protection/Medical_Services/documents/pdf/TxFosterCareParameters.pdf
Turney,K.,Wildeman,C.(2016).MentalandPhysicalHealthofChildreninFosterCare.Pediatrics,138(5).
U.S.DepartmentofHealthandHumanServices,AdministrationforChildrenandFamilies,Children’sBureau
(2012).Makinghealthychoices:Aguideonpsychotropicmedicationsforyouthinfostercare.Washington,D.C.:
Author.RetrievedSeptember21,2015fromhttps://www.childwelfare.gov/pubs/makinghealthychoices/
U.S.GovernmentAccountabilityOffice.(2011).Fosterchildren:HHSguidancecouldhelpstatesimproveoversight
ofpsychotropicmedication(PublicationNo.GAO-12-270T).Washington,D.C.:Author.DocumentNumber)
Wilson,D.(2009,September11).Poorchildrenlikeliertogetantipsychotics.NewYorkTimesfrom
http://www.nytimes.com/2009/12/12/health/12medicaid.
Zito,J.M.,Safer,D.J.,Sai,D.,Gardner,J.F.,Thomas,D.,Coombes,P.,Mendez-Lewis,M.(2008).Psychotropic
medicationpatternsamongyouthinfostercare.Pediatrics,121(1).http://doi.org/10.1542/peds.2007–0212