Psychotropic Medication for Children in Texas Conservatorship

1. Psychotropic Medication for Children in Texas ConservatorshipAnnualEducation Reach for TexansMay 30, 2014 REGION 03 CHILD PROTECTIVE SERVICES Sandra Galindo, BSN, RN Regional Nurse Consultant sandra.galindo@dfps.state.tx.us 214/583-4151 office number

2. Goal Update and review of 2013 Psychotropic Medication Utilization Parmetner for Children in Foster Care. Foster Parent

3. Objectives • Become familiar with the DFPS Psychotropic Medication Utilization Parameters • Briefly discuss non-pharmacological therapies. • Review “Criteria Indicating Need for Further Review of a Child’s Clinical Status” • Explore and practice using Psychotropic Medication Tables. • generic/brand names - Schedules • Initial dosages - Black box warnings • Maximum dosages - Warnings & precautions • Implications for foster parents and all team members. Foster Parent

4. Disclaimers The contents of this training is for informational purposes only and does not substitute for professional medical advice. “Always discuss specific questions or concerns with the child’s prescribing doctor.” There may be additional requirements for residential child care providers or child placing agencies, i.e.,: Their agency’s specific policies and procedures on psychotropic medications. Who may consent to the use of psychotropic medications for children who are not in DFPS conservatorship.

5. Some children experience emotional or behavioral problems. Foster Parent

6. Contributing Factors to Positive Outcomes • Not changing placement or caregivers • Caregiver characteristics are important: • patient, understanding, kind, loving, and gentle • gives clear instructions about expectations and house rules. • gives consistent consequences when rules are broken. • teaches the child coping skills and how to control their behavior and emotions in an age appropriate way. • praises the child for positive behaviors. • Remember, children may act out as they adjust to a new home and learn new rules. Foster Parent

7. Non-pharmacological Interventions These specific methods a caregiver can use to help a child manage behavior: • Before considering psychotropic medications, consider psychosocial therapies, behavior strategies, and other non-pharmacological (non-medication) interventions • If psychotropic medications are started, provide non-pharmacological interventions along with psychotropic medications. • Each child is different, so the strategies should be specific to the child’s needs and discussed with the child’s therapist or medical provider. • Individual therapy (child only) • Family therapy • Group therapy Foster Parent

8. What is a symptom? • Something experienced or felt • A sign of an existence of something, especially something undesirable • May indicate a disease or other disorder • May change how a person feels • May affect daily activities, like school, jobs, relationships • May cause dangerous actions Foster Parent

9. B E H A V I O R S D IA G N O S I S Foster Parent

10. Seeking Medical Help When: • if a child has serious symptoms or • is not getting better with other interventions, • is a danger to himself/herself or others Who: A primary care provider, who is not a psychiatrist, may prescribe psychotropic medications for: • Attention Deficit Hyperactivity Disorder (ADHD). • Mild anxiety. • Mild depression. For more complex problems, see a psychiatrist. Foster Parent

11. Purpose of Psychotropic Meds To treat emotional and behavioral health symptoms and disorders. Foster Parent

12. PsychotropicMedication Utilization Parameters for Foster Children • Developed by: • Texas Department of Family and Protective Services • The University of Texas at Austin College of Pharmacy with review and input provided by: • Federation of Texas Psychiatry • Texas Pediatric Society • Texas Academy of Family Physicians • Texas Medical Association • December 2010 Foster Parent

13. Psychotropic Medication Utilization Parameters for Foster Children • Give general principles for doctors who prescribe psychotropic medications to children in DFPS conservatorship. • Developed by a group of experts, such as child and adolescent psychiatrists, pediatricians, pharmacologists, and other mental health experts and are updated regularly. • They are based on reliable research and what has worked best in treating other children with similar conditions. • They list eight criteria that point out the need to review the psychotropic medications prescribed to a child. Foster Parent

14. “Off label” prescriptions: Doctors decision to prescribe “off label” medications are based on: • What medications have worked for children with similar conditions. • What they learn from research and literature. • What they think is best for each child based on their clinical experience. Foster Parent

15. Considerations • Child psychiatry is continually evolving, so changes will occur. • Lack of FDA approval is NOT synonymous with inappropriate for children. • The list does not include all possible medications. • If a medication is not listed, it may still be appropriate. 5. Many of these medications can be used for non-psychiatric indications. 6. It can be appropriate to exceed the usual MAX dose. 7. Know the difference between a side effect and adverse reactions. Foster Parent

16. Non- approved Medicationsby the Federal Drug Administration? • Remember FDA regulates medications, not doctors. • Most medications regulated by FDA are based on research in adults. • Research & clinical experience lead to “off label” prescribing. Foster Parent

17. Medications are only one piece of the puzzle….. Foster Parent

18. http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdfhttp://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf Foster Parent

19. Criteria Indicating Need for Further Review of a Child’s Clinical Status • Absence of a thorough assessment or • DSM IV diagnosis • Four or more psychotropic medications prescribed concomitantly (at the same time) • Prescribing: • 2 or more concomitant antidepressants • 2 or more concomitant alpha agonists • 2 or more concomitant anti-psychotics • 2 or more concomitant stimulants • 3 or more concomitant mood stabilizers Foster Parent

20. Criteria Indicating Need for Further Review of a Child’s Clinical Status • Prescribed psychotropic medication is NOT consistent with the patient’s diagnosis or target symptoms • Poly-pharmacy is given before mono-therapy • Psychotropic med dose exceeds usual recommended doses. Foster Parent

21. Criteria “Continued” • Psychotropic medications prescribed for children at a very young age, i.e.,: • Stimulants-less than 3 years of age • Alpha Agonists less than four (4) years of age • Anti-depressants - less than 4 years of age • Anti-psychotics - less than 4 years of age • Mood stabilizers – less than 4 years of age • Prescribing by a primary care provider for a diagnosis for other than the following: • ADHD • Uncomplicated anxiety disorders • Uncomplicated depression • Appropriate monitoring of glucose and lipids at least every 6 months for continuous prescribed anti-psychotics Foster Parent

22. Psychotropic Medication Tables • generic/brand names • Initial dosages • Maximum dosages • Schedules • Black box warnings • Warnings & precautions Foster Parent

23. Side Effects vs. Adverse Reactions Side Effects • Common • Expected • Go away • Intervention usually not required Adverse Reactions • Unwanted • Uncommon • Unexpected • Life threatening • Requires immediate action Foster Parent

24. Some behaviors are normal. Foster Parent

25. Foster Parent Implications Before the visit to the psychiatrist, find out as much of this information as possible from the: • Caseworker • Previous caregiver, including birth parent • Ask for and if needed, request copies of medical records • Ask for and if needed, request previous psychological evaluations • Previous medications • Any adverse reactions to medications . Foster Parent

26. Foster Parent Implications: • Share with the doctor (and the worker) any changes, good or bad, i.e., • The addition of another child to the foster home, i.e., birth or placement another child • Any changes in sleep • Any changes in grades • Changes in diet or weight loss or gain • Stress • Changes in Mood • Any changes related to alcohol or other substance experimentation. Foster Parent

27. Foster Parent Implications: • Avoid rescheduling appointments. • As the medical consenter and/or foster parent, practice “Assent” • Discuss Psychotropic Medications with children, especially teens. • Talk to the child in a way that the child can understand. • Make sure the child understands why he or she is taking these medications. • Tell the child what he or she can expect from any tests or treatment. • Ask the child if he has any questions or concerns. Foster Parent

28. More Implications • Share with CPS and CASA the child’s medications and the psychiatric plan of treatment: • Know the diagnosis or target symptom the medication prescribed for • Know the generic/brand name, dosage, route & frequency given • Note and document the child’s progress on the medication • Know adverse reactions or side effects to the medications. • Are there special instructions for giving any medications, i.e., with food or at a certain time of day. Foster Parent

29. Foster Parent Implications • Know your role and responsibilities as the medical consenter. • Be familiar with the court report done by the caseworker. Foster Parent

30. Foster Parent Resources • For help, contact a Behavioral Health service manager with STAR Health. • Become familiar with the Health Passport at http://www.fostercaretx.com/ • Call the regional nurse consultant for help and/or other subject matter experts. Foster Parent

31. Foster Parent Resources • Take a class on behavior intervention or trauma-informed care. • Work with the child’s therapist, the school, CPS staff, and others to find interventions that work and make sure everyone is using the same interventions. • Consistent interventions and consequences help the child learn to manage his or her behavior and emotions. Foster Parent

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