Psychotropic Medication for Children in Texas Foster

Psychotropic Medication for Children in Texas Foster Care Training for : § Child Protective Services (CPS) Staff § Relatives and Kinship Caregivers § Foster Parents § Residential Providers § Youth Medical Consenters Effective 11/20/13 Psychotropic Medications 1

Disclaimers o This training explains the State's expectations for the safe and effective use of psychotropic medications by children in Texas Department of Family and Protective Services (DFPS) conservatorship. Always discuss specific questions about the medications with the child's doctor. o Residential child care providers must have additional training covering: n Their specific policies and procedures on psychotropic medications. n Who may consent to the use of psychotropic medications for children who are not in DFPS conservatorship. Residential Child Care Licensing Minimum Standards Section 748. 885 and Section 749. 885 Effective 11/20/13 Psychotropic Medications 2

What is a psychotropic medication? It is a medication that is prescribed for the treatment of symptoms of psychosis or another mental, emotional, or behavioral disorder and that is used to exercise an effect on the central nervous system to influence and modify behavior, cognition, or affective state. Effective 11/20/13 The term includes the following categories psychomotor stimulants; antidepressants; antipsychotics or neuroleptics; agents for control of mania or depression; antianxiety agents; and sedatives, hypnotics, or other sleep-promoting medications Psychotropic Medications 3

Helpful Information and Definitions o o o Caregiver means a foster parent, relative or kinship placement. Residential provider means a child placing agency or residential operation or their staff. The medical consenter is the person named by the court or DFPS to make medical decisions for a child in DFPS conservatorship. n n o o Foster parents , relatives (“kinship caregivers”) or other live-in caregivers are the medical consenters for most children in foster care and DFPS custody. DFPS caseworkers and I See You workers will typically be the medical consenters for children living in residential facilities with shift staff (other than emergency shelters). As a last resort, a specially trained CPS Human Services Technician may provide consent. Requirements of the medical consenter apply to both the Primary and Backup medical consenter. STAR Health is the health plan for most children in DFPS conservatorship means the child is in the legal custody of the State of Texas and DFPS. Effective 11/20/13 Psychotropic Medications 4

Purpose To educate CPS staff, foster parents, relatives (kinship), youth medical consenters, and residential providers about psychotropic medications, help them make informed decisions, and monitor children in DFPS conservatorship who are prescribed these medications. Effective 11/20/13 Psychotropic Medications 5

Goals & Objectives 1. 2. 3. 4. Understand that other interventions should be considered along with psychotropic medications. Understand the need for a complete psychiatric evaluation (including physical examination) before making a decision about psychotropic medications and treatments. Understand the responsibility of the medical consenter to decide whether or not to give informed consent for each psychotropic medication prescribed for a child. Understand how psychotropic medications are used. Effective 11/20/13 Psychotropic Medications 6

Goals & Objectives 5. 6. 7. 8. Understand how to monitor a child for possible side effects or to see if the psychotropic medication is working. Know what to do if you have concerns about the psychotropic medications prescribed to children in your care. Know about the Psychotropic Medication Utilization Parameters for Children in Foster Care. Be aware of how various classes of psychotropic medications work, their side effects, and examples of medications in each class. Effective 11/20/13 Psychotropic Medications 7

Psychotropic Medication Training Module I Decisions About Consenting & Psychiatric Evaluation Effective 11/20/13 Psychotropic Medications 8

Legislative Requirements for Medical Consent Training o Medical Consenters are required by Texas law to receive training on: n Informed consent for psychotropic medication and n Non-pharmacological (non-medication) interventions that should be considered along with psychotropic medications This information is covered in both this training and the DFPS Medical Consent training. Effective 11/20/13 9

What Is a Medical Consenter? o A person who has been given legal authority by DFPS or the court to make health care decisions for a child in the custody of DFPS. o This means that the person decides whether or not to consent to medical, dental, eye care and behavioral health (mental health) care for children in DFPS custody including decisions about psychotropic medications. Effective 11/20/13 10

Use of Psychotropic Medications Most children in DFPS conservatorship never need psychotropic medications. Children who are traumatized by abuse, neglect or separation may show negative behaviors or signs of emotional stress that are a normal reaction to what they have been through. Also, all children act out at different stages of their lives. For example, two-year olds commonly have temper tantrums and teenagers often rebel. Effective 11/20/13 Psychotropic Medications 11

Use of Psychotropic Medications Support from caregivers knowledgeable of trauma-informed care can help a child heal. But some children need medication to cope with the trauma of abuse, neglect or separation. Other children need medication to treat behavioral health disorders that they inherited or developed, such as Attention Deficit Hyperactivity Disorder (ADHD), severe depression, or psychosis. Psychotropic medications may help children function at home, in school, and in their daily lives. They may need these medications temporarily to treat emotional stress or long-term to treat life-long behavioral health disorders. Effective 11/20/13 Psychotropic Medications 12

The Importance of an Appropriate Environment o Most children will heal with stability, consistency, nurture and support of caregivers knowledgeable of trauma-informed care. o This means that the child does not change placements and the caregiver: n Is patient, understanding, kind, loving, and gentle. n Gives clear instructions about expectations and house rules. n Gives consistent consequences when rules are broken. n Teaches the child coping skills and how to control their behavior and emotions in an age appropriate way. n Praises the child for positive behaviors. Effective 11/20/13 Psychotropic Medications 13

The Importance of an Appropriate Environment Children may act out as they adjust to a new home and learn new rules. Caregivers should expect that adjustment takes time and give appropriate support and acceptance. If given safe, positive, nurturing, consistent trauma-informed care most children will learn to trust, feel safe, and learn to control their emotions and behavior in way that is appropriate for their age. Effective 11/20/13 Psychotropic Medications 14

Non-Pharmacological Interventions Psychosocial therapies, behavior strategies, and other nonpharmacological (non-medication) interventions are to be considered by the medical consenter before or along with psychotropic medications. n Non-pharmacological interventions are specific methods a caregiver can use to help a child manage behavior. n This may include therapy and specific behavior modification strategies. n 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. Effective 11/20/13 Psychotropic Medications 15

Non-pharmacological Interventions We will discuss severe symptoms later. But, in most cases, you should try non-pharmacological interventions before psychotropic medications. You can get help by: n Talking to the child’s CPS caseworker or child placing agency (CPA) staff or treatment team about how to help the child manage behaviors or deal with emotional stress. n Talking to the child’s caseworker or CPA staff or treatment team about seeking behavior health therapy. This is professional counseling that may be: o Individual therapy (child only) o Family therapy o Group therapy Effective 11/20/13 Psychotropic Medications 16

Non-pharmacological Interventions (cont. ) § Taking a class on behavior intervention or trauma-informed care. Talk to CPS, your CPA, or your residential operation to find out about classes. § Working 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. Effective 11/20/13 Psychotropic Medications 17

Seek Medical Help If a child has serious symptoms or is not getting better with nonpharmacological interventions, the caregiver or medical consenter should talk to a doctor. Anytime a child is a danger to himself/herself or others, the caregiver or medical consenter should immediately contact the doctor. Examples include suicidal or violent thoughts or actions. A primary care provider may be able to diagnose and treat some behavioral health disorders including prescribing psychotropic medications. For more complex problems, or if you would like a further assessment of the child you may request an appointment with a psychiatrist. The child and adolescent psychiatrist will do a complete psychiatric evaluation and make a recommendation about treatment. Ask the child’s primary care provider if you are not sure if the child needs to see a psychiatrist. Effective 11/20/13 Psychotropic Medications 18

Complete Psychiatric Evaluation What the psychiatrist will do: o Talk to the child o Talk to the caregivers and medical consenter o Review medical history o If needed, get laboratory studies such as blood tests or electrocardiograms (EKGs). If needed, get special assessments such as: n A psychological evaluation which is a mental examination and testing by a psychologist n Educational assessments which help find out the child's ability to learn material at an appropriate age and grade level and the best way for the child to learn n Speech and language evaluation to assess the child’s ability to understand language, express him or herself, and speak clearly o Give a diagnosis o Recommend the best way to treat the child Effective 11/20/13 Psychotropic Medications 19

Complete Psychiatric Evaluation What the psychiatrist will need to know: o o o o Description of child’s problems and symptoms Information about health, illness and treatment (both physical and mental) including current medications Parent and family health and psychiatric histories Information about the child’s abuse and neglect history Information about the child's development Information about school and friends Information about family relationships in the child’s birth family and home or living arrangement It is important for a child’s caregiver or medical consenter to find out as much of this information as possible before taking the child to the psychiatrist. The psychiatrist needs to know how the child is doing in all areas of his or her life. Effective 11/20/13 Psychotropic Medications 20

Diagnoses of Mental Health Disorders Before prescribing psychotropic medications for a child, the psychiatrist will give the child a diagnosis using the Diagnostic and Statistical Manual of Mental Disorders IV (DSM). The DSM is used to evaluate a person in 5 areas called axes. AXIS I: Clinical Disorders Clinical disorders, such as Major Depression, Attention Deficit Hyperactivity Disorder, Bipolar Disorder, Post Traumatic Stress Disorder, Attachment Disorder, Learning Disability, Pervasive Developmental Disability, Autism Spectrum Disorder AXIS II: Personality Disorders such as Borderline Personality Disorder and Histrionic Personality Disorder Effective 11/20/13 Psychotropic Medications 21

Diagnoses of Mental Health Disorders AXIS III: General Medical Conditions Physical health conditions, such as Asthma, Diabetes, Fetal Alcoholism Spectrum Disorder AXIS IV: Psychosocial and Environmental Problems Factors that describe a person’s life circumstances, such as child abuse, placement disruptions, problems getting along with peers and problems in school AXIS V: Global Assessment of Functioning Scale This scale assesses how a person is functioning in all areas of his or her life. For children under 18 years, this scale measures how the child is functioning in his or her family, with peers and in school. The scale goes from 1 to 100, with 100 being the highest score. Effective 11/20/13 Psychotropic Medications 22

Diagnoses of Mental Health Disorders If the caregiver or medical consenter needs help understanding the diagnosis, they should talk with the medical provider. Effective 11/20/13 Psychotropic Medications 23

Psychiatrist’s Recommendations The psychiatrist will make a recommendation for treatment, such as therapy or psychotropic medication, after completing the psychiatric evaluation and making a diagnosis. The medical consenter should be diligent while working with the medical provider to: o Get answers to questions about medication and therapy o Find treatments that help the child get better o Determine what treatment is in the best interest of the child Effective 11/20/13 Psychotropic Medications 24

Making Decisions about Psychotropic Medications The psychiatrist must obtain “informed consent” from the child’s medical consenter before prescribing a psychotropic medication. This means the doctor must give the medical consenter enough information to decide whether or not to consent for the child to have the medication. The doctor must also allow the medical consenter to ask questions. The process of understanding the risks and benefits of giving the medication to the child is a vital part of informed consent. Effective 11/20/13 Psychotropic Medications 25

What does “undue influence” mean to me? o Making an informed decision about behavioral health treatment or medications without “undue influence” means that the medical consenter is deciding based on what is best for the child, not because of pressure to consent to the medication or treatment. o For example, a decision should not be based on the child’s school insisting the child be put on medications before they can return to school. Effective 11/20/13 Psychotropic Medications 26

Informed Consent Before Prescribing Psychotropic Medications According to Texas law, your consent to giving a psychotropic medication is valid only if: o It is given voluntarily and without undue influence; and o The consenter receives information (given verbally or in writing) describing: n the specific condition to be treated; n the beneficial effects on that condition expected from the medication; n the probable health and mental health consequences of not consenting to the medication; n the probable clinically significant side effects and risks associated with the medication; and n the generally accepted alternative medications and non-pharmacological (non-medication) interventions to the medication, if any, and the reasons for the proposed course of treatment Effective 11/20/13 Psychotropic Medications 27

Improving Disparate Health Treatment It is important for CPS caseworkers and medical consenters to be aware of research about healthcare and disparities in treatment and ensure that decisions about services are made with the best interest of each individual child or youth in mind. o Children and youth [in the child welfare system] living with relatives have been found to have lower rates of mental health and behavioral problems than do children in foster care and group care, although they have higher rates of these problems than the general population does and of those in non-child welfare related (informal) kinship placements. Source: Gleeson, J. P. (2007). Kinship Care Research and Literature: Lessons Learned and Directions for Future Research. Kinship Report. Child Welfare League of America, 1(2), 1, 8 -11. Effective 11/20/13 Psychotropic Medications 28

Improving Disparate Health Treatment (cont. ) o Parents should be expected and encouraged to participate in all school, medical and therapeutic appointments. Technical Assistance Bulletin, Right from the Start: The CCC Preliminary Protective Hearing Benchcard, A Tool for Judicial Decision-Making, published by the National Council of Juvenile and Family Court Judges, Reno, Nevada. © 2010, National Council of Juvenile and Family Court Judges. All Rights Reserved. http: //www. ncjfcj. org/sites/default/files/Right%20 from%20 the%20 Start_1. pdf o CPS caseworkers and caregivers should encourage participation when in the child’s best interest, taking safety into account. Effective 11/20/13 Psychotropic Medications 29

Improving Disparate Health Treatment (cont. ) o Recent research has found that African Americans are diagnosed with schizophrenia at a disproportionally high rate compared to non-Latino whites, which researchers say can lead to inappropriate treatment, including excessive use of antipsychotics, excessive dosing, and under-prescribing of mood stabilizers. Arch Gen Psychiatry. 2012; 69(6): 593 -600. Published online February 6, 2012. doi: 10. 1001/archgenpsychiatry. 2011. 2040 o A Medical Consenter should be aware that stereotypes and biases about race and ethnicity may impact clinical assessment in mental health care, and should discuss with the doctor whether the child’s assessment, diagnosis or recommended treatment has been influenced by factors related to race or ethnicity. Effective 11/20/13 Psychotropic Medications 30

Consenting to Psychotropic Medications Informed consent must be obtained from the medical consenter for each new medication and for changes in the dose. A signed Psychotropic Medication Treatment Consent form (DFPS Form 4526) is required for each new psychotropic medication. n The medical consenter must provide to the CPS caseworker all completed Forms 4526, Psychotropic Medication Treatment Consent, as soon as possible or within 5 business days. If the medical consenter is not a CPS employee, he or she must also let the CPS caseworker or supervisor know about the decision to consent to the medication or dose changes or the decision not to consent by the next business day by e-mail or other written communication. If the medical consenter is not sure whether to consent to the medication, he or she should discuss his or her concerns first with the prescribing medical provider and also with others involved in the case, such as the CPS caseworker, child placing agency staff, or residential operation treatment team. Effective 11/20/13 Psychotropic Medications 31

Monitoring Use of Psychotropic Medications Every 90 Days Texas law requires the medical consenter for a child in foster care to ensure that a child prescribed a psychotropic drug has an office visit with the prescribing physician, physician assistant, or advanced practice nurse at least once every 90 days to allow the practitioner to: n appropriately monitor for side effects of the drug; and n determine whether the drug is helping the child achieve the treatment goals, and n whether continued use of the drug is appropriate. Effective 11/20/13 Psychotropic Medications 32

What Does Informed Consent Involve? Here are some things the medical consenter should discuss with the doctor: o What is the child’s diagnosis and symptoms? o How will the psychotropic medication help the child? o Does the medication have risks? o Are there alternatives such as interventions that do not require the child to take a psychotropic medication? Effective 11/20/13 Psychotropic Medications 33

Other Questions to Ask the Doctor o What is the name of the medication? Is it known by other names? o How effective has it been for other children who have a similar condition to the child? o How will the medication help the child? How long before I see improvement? o Is this medication approved by the Federal Food and Drug Administration (FDA) for the child's condition? If not, (i. e. , it is being prescribed "off-label"), why is this medicine being recommended? o What are the side effects that occur with this medication and how will I know if the child is experiencing any of these effects? Effective 11/20/13 Psychotropic Medications 34

Other Questions to Ask the Doctor o o o What is the recommended dosage? How often will the medication be taken? Does the child need laboratory tests (e. g. electrocardiograms, blood tests, etc. ) before taking the medication? Does the child need any tests while taking the medication? Will a child and adolescent psychiatrist monitor the child's response to the medication and change the dose if necessary? Who will check the child's progress and how often? Does the child need to avoid other medications or foods while taking this medication? Does this medication interact with other medications (prescription and/or over-the-counter) the child is taking? Effective 11/20/13 Psychotropic Medications 35

Discuss Psychotropic Medications with Children It is important to talk with the child about taking psychotropic medications. You should: o Talk to the child in a way that the child can understand. o Make sure the child understands why he or she is taking these medications. o Tell the child what he or she can expect from any tests or treatment. Effective 11/20/13 Psychotropic Medications 36

Why talk with a child about psychotropic medications? Involving the child; o Helps children feel more in control and builds trust. o May help make the treatment more successful. o Helps children learn to make medical decisions as adults. Children should have more input into decisions about taking psychotropic medications as they get older. However, the medical consenter should always make the final decision based on what is best for the child. NOTE: The court may allow 16 or 17 year old youth to consent to some or all of his/her own medical care. Effective 11/20/13 Psychotropic Medications 37

Duties for the Attorney Ad Litem Texas law requires Attorneys Ad Litem to advise youth who are 16 years of age and older of their right to ask the court to authorize the youth to be his or her own medical consenter under Section 266. 010 of the Family Code. o The youth must take the DFPS approved Medical Consent Training. o The youth must still provide medical information to the CPS caseworker, and is expected to make medical decisions in his or her best interest. Effective 11/20/13 Psychotropic Medications 38

Transitional Living Services Program requirements DFPS must ensure that a youth's transition plan includes provisions to assist the youth in safely managing medication usage after exiting foster care, including information that educates the youth about: n the use of the medication; n resources available to assist the youth in safely managing the medication; and n informed consent and the right of the youth to be his or her own medical consenter Effective 11/20/13 Psychotropic Medications 39

Psychotropic Medication Training Module 2 Giving Psychotropic Medications, Monitoring, and Follow Up Effective 11/20/13 Psychotropic Medications 40

Giving Psychotropic Medications to Children o Remember that psychotropic medications are only one strategy to help the child. The caregiver or residential provider must continue to provide a stable environment and consistent behavior intervention and explore nonpharmacological (non-medication) interventions with healthcare providers. The child may also need behavior health therapy. o Always read and keep the insert from the pharmacy that comes with each medication. The insert tells you important information on how to give the medication and on possible side effects to watch for. o Store the medication in the original container that came from the pharmacy. Effective 11/20/13 Psychotropic Medications 41

Court Review – Summary of Care For a child receiving psychotropic medication, the law requires that the summary of medical care that is presented to the court at each hearing where medical care is reviewed must include: o a description of the psychosocial therapies, behavior strategies, or other non-pharmacological (non-medication) interventions that have been provided to the child; and Effective 11/20/13 o the dates of any office visits the child has had with the prescribing medical provider since the previous hearing. 42

Notifications about psychotropic medications o The child’s medical consenter must give information in writing to the CPS Caseworker about any new psychotropic medications and dosage changes of psychotropic medications prescribed to a child. o The medical consenter must provide this to the caseworker by the next business day in writing by e-mail or fax. o The CPS Caseworker must provide this information to the child’s parent at the first scheduled meeting after any medication changes. Effective 11/20/13 43

More About Giving Psychotropic Medications o Give the medication exactly as prescribed and never more or less unless directed by the doctor. o Never quit giving the medication to the child unless the doctor tells you to quit. Some psychotropic medications require weaning off gradually. Always follow the doctor’s instructions when stopping medications. o Follow the doctor’s direction for giving the medication. For example, the doctor may tell you to give the medication at a certain time of day or to make sure the child does not eat certain foods. Effective 11/20/13 Psychotropic Medications 44

More About Giving Psychotropic Medications o Watch to make sure the child takes the medication. o Never give a child a medication that is prescribed for someone else. o Keep a medication log for each child. Write down the date, time, and who gave the medication to the child. (Residential Child Care Licensing Minimum Standards Section 748. 2151 and Section 749. 1541) o Coordinate with the doctor to make sure you get refills on time. Effective 11/20/13 Psychotropic Medications 45

What Are Side Effects? o These are uncomfortable effects such as stomach aches, drowsiness, dizziness, sleep problems, tremors, and weight gain that may occur when starting a new medication, increasing the dose, or stopping the medication. o These may get better with healthy diet, rest and exercise. o These may make the child feel very uncomfortable or the side effect may interfere with functioning, and the medical consenter should call the child's doctor and seek advice if this happens. Effective 11/20/13 Psychotropic Medications 46

Adverse Reactions Adverse reactions: o Are uncommon and unexpected. o May be an allergic reaction. o Are likely harmful if the child keeps taking the medication. o May be life threatening. Immediately talk to the child’s doctor and follow his or her directions if there is an adverse reaction. Effective 11/20/13 Psychotropic Medications 47

Side Effects and Adverse Reactions Also see (Residential Child Care Licensing Minimum Standards Section 748. 2233 and Section 749. 1583 regarding side effects and Section 748. 2231 and Section 749. 1581 regarding adverse reactions) o Always talk to the child’s doctor anytime you have a concern about how a medication is affecting a child. o Always report adverse reactions to the doctor right away. o Call 911 or immediately take the child to the emergency room if the child is having an adverse reaction that is life threatening. o Remember to report this information to CPS and the Child Placing Agency if the child is placed in a residential operation. Effective 11/20/13 Psychotropic Medications 48

Monitoring and Follow Up o Watch for side effects or adverse reactions and report these to the doctor. o Watch for any changes in the child’s behavior or symptoms that may show whether the medication is working or not. o Write down in the child’s record any side effects, changes in behavior, or contacts with the doctor or his or her office about the medication. Effective 11/20/13 Psychotropic Medications 49

Monitoring and Follow Up o Take the child to the doctor or other healthcare professional who prescribed the medication at least once every 90 days. The doctor will evaluate how the child is doing and whether the medication is working. o Attend each visit with the child and prescribing doctor. o Report side effects, adverse reactions, and how the child is doing on the medication to the child’s CPS caseworker and your child placing agency or residential operation. Effective 11/20/13 Psychotropic Medications 50

What to Tell the Doctor During Follow up Visits Some things to tell the doctor about are: o Changes in behavior, mood, appetite or sleep. o Changes in how the child is doing in school. o Significant things that are happening to the child (example: loss of best friend, major disappointment, termination of parental rights, etc. ). o Changes in how the child gets along with others. o Suspected alcohol or drug use. o Weight gain or loss. o Any side effects of the medication. Effective 11/20/13 Psychotropic Medications 51

Psychotropic Medication Utilization Parameters for Foster Children o The Parameters give general principles for doctors who prescribe psychotropic medications to children in DFPS conservatorship. o They were developed by a group of experts, such as child and adolescent psychiatrists, pediatricians, pharmacologists, and other mental health experts and are updated regularly. o They are based on reliable research and what has worked best in treating other children with similar conditions. o They list nine criteria that point out the need to review the psychotropic medications prescribed to a child. o The Parameters are available on the DFPS website at: http: //www. dfps. state. tx. us/Child_Protection/Medical_Services /guide-psychotropic. asp Effective 11/20/13 Psychotropic Medications 52

Psychotropic Medication Utilization Review (PMUR) o A PMUR is the process STAR Health uses to screen children’s psychotropic medications and review them when they fall outside the Parameters. o Being outside the Parameters does not mean that the psychotropic medications are harmful for the child. o Rather, being outside Parameters means that a STAR Health child and adolescent psychiatrist needs to review the case to see how the child is doing and make sure the medications are the best treatment for the child. Effective 11/20/13 Psychotropic Medications 53

When Does STAR Health Do a PMUR? STAR Health does a PMUR after children have taken the medications for at least 60 days and they fall outside the Parameters in certain categories. The categories are: o All children under the age of four. o Any child who is taking: n 2 or more stimulant medications. n 2 or more alpha agonists. n 2 or more antidepressant medications. n 2 or more atypical antipsychotic medications. n 3 or more mood stabilizers. o Any child with 4 or more psychotropic medications. o Antipsychotic medication(s) prescribed continuously without appropriate monitoring of glucose and lipids at least every 6 months. Effective 11/20/13 Psychotropic Medications 54

What Triggers a PMUR? A PMUR can happen in several ways, including: o An automated process using pharmacy information that identifies when children’s medications are outside the Parameters. o When STAR Health service managers or coordinators call caregivers and medical consenters to do health screening on children who are newly placed or have changed placements, and the results warrant a review. o When someone, such as a caregiver, medical consenter, CPS staff, attorney, CASA, residential provider or other person has a concern and asks STAR Health for a review. o When a court asks for a review. Effective 11/20/13 Psychotropic Medications 55

What Happens During a PMUR? When a child’s psychotropic medications fall outside of the Parameters, a STAR Health child and adolescent psychiatrist reviews the child’s medical records and talks to the doctor who prescribed the medication. Sometimes medications are changed. Other times the child keeps taking the medications, even though the medications are outside Parameters, because the child’s condition is complex and the medications are helping the child. The STAR Health psychiatrist will consult with the prescribing clinician again within 60 to 90 days if the medication regimen remains outside of the Parameters. You may request a PMUR by calling STAR Health Member Services at 1 -866 -912 -6283. You may learn more in the STAR Health Frequently Asked Questions document at http: //www. dfps. state. tx. us/Child_Protection/Medical_Servic es/guide-psychotropic. asp Effective 11/20/13 Psychotropic Medications 56

Health Passport o Is a web-based system for children enrolled in STAR Health that keeps track of medical information. o Includes prescriptions, diagnoses, medical and dental visits, immunizations and allergy information. o Is accessible by Medical Consenters, DFPS staff and Links with the Patient information leaflet for certain authorized users. medications are useful o Is accessed by using tools within the Health registration instructions Passport for medication found on Form 2085 -B usage and side effects. Designation of Medical Consenter. Effective 11/20/13 57

Is it okay for my child to take a medication that does not have FDA approval? o o o Many medications used to treat young people with mental illness are safe and effective. Many psychotropic medications, however, do not have Federal Food and Drug Administration (FDA) approved labeling for use in children and adolescents due to the majority of medication being approved by the FDA based on research in adults. Over time, clinical studies and research may support the use of the medication for an "off-label" in children and/or adolescents. The DFPS prescribing Parameters include "Literature based maximum doses" for medications where there is support for "off-label" use. However, many medications have not been studied or approved for use with children. Researchers are not sure how these medications affect a child’s growing body. Effective 11/20/13 Psychotropic Medications 58

Psychotropic Medication Training Module 3 Overview of Psychotropic Medications Effective 11/20/13 Psychotropic Medications 59

How Do Psychotropic Medications Work? Psychotropic medications act on the brain and central nervous system. They change the way chemicals in the brain called “neurotransmitters” send messages between brain cells through a synapse or crossing. Each psychotropic medication is used to treat certain “target” symptoms. Effective 11/20/13 Psychotropic Medications 60

Overlapping Target Symptoms (Behaviors) Anger/ Depression ADHD Conduct Disorder Oppositional Defiant Disorder Anxiety Disorder Bipolar Disorder Impulsive x x x x x Obsessive Compulsive Disorder PTSD x Effective 11/20/13 Withdrawn Sad Destructive Defiant Anxious x x x Difficulty w/ Focus Manipulative x x x x x Psychotropic Medications x x 61

Classes Of Psychotropic Medications The classes (types) of psychotropic medications are: • Stimulants • Antidepressants • Antipsychotics • Mood stabilizers • Antianxiety agents We will now discuss the different classes of psychotropic medications used in children, and examples of medications in each class and their side effects. The medication your child is taking may not be mentioned since new medications come out all the time. It is important to read the pharmacy insert and talk with the doctor to learn about each medication. Effective 11/20/13 Psychotropic Medications 62

Stimulants are commonly used to treat Attention-Deficit Hyperactivity Disorder (ADHD). Symptoms of ADHD interfere with functioning at school and in daily living and may include: n n n Short attention span. Inability to stay still. Being impulsive. Stimulants may be short acting or long acting. Short acting means that they act right away but do not last a long time. Long acting means that they take longer to act but last longer. Some children need to take a short acting and a long acting stimulant to get coverage throughout the day. Taking a short acting and a long acting stimulant together counts as only one stimulant and is not outside the Parameters. Effective 11/20/13 Psychotropic Medications 63

Stimulants Examples of short acting stimulants: Examples of long acting stimulants: o Amphetamine (Adderall) o Dexmethylphenidate (Focalin) o Methylphenidate (Ritalin, Metadate, Methylin) o Dextroamphetamine (Dexedrine, Dextrostat) o Amphetamine (Adderall XR) o Dexmethylphenidate (Focalin XR) o Methylphenidate (Concerta) o Lisdexamfetamine (Vyvance) Effective 11/20/13 Psychotropic Medications 64

Possible Side Effects and Adverse Reactions of Stimulants Side Effects o o o o o Adverse Reactions Decreased appetite Weight loss Headaches Stomachaches Trouble getting to sleep Jitteriness Social withdrawal Tics, sudden repetitive movements or sounds Aggressive behavior or hostility Psychotic or manic symptoms Effective 11/20/13 o o o Sudden death in children with pre-existing serious heart problems High blood pressure Problems with growing, such as a slower growth rate Psychotropic Medications 65

Other ADHD Treatments Sometimes medications that are not stimulants are used to treat ADHD. These medications come from different classes. You will need to read the pharmacy insert to learn about side effects and adverse reactions to these medications. A child in your care may be prescribed one of these medications. Examples are: o Clonidine (Catapres, Kapvay)--used to treat high blood pressure in adults but causes sedation in children in small doses o Guanfacine (Tenex, Intuniv)--used to treat high blood pressure in adults but causes sedation in children in small doses o Atomoxetine (Strattera)--newer antidepressant, in rare cases causes suicidal thought risk o Bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL)--newer antidepressant o Imipramine (Tofranil)--older antidepressant, usually used to treat bed wetting, but may be used to treat ADHD Effective 11/20/13 Psychotropic Medications 66

More About Treating ADHD o Stimulants are usually the first medication tried for ADHD. o Sometimes antidepressants are given for ADHD if 2 to 3 stimulants are tried and do not work. o Your child’s doctor should start the stimulant at the lowest dose and only increase the dose as needed. o A short acting stimulant should last for about 4 hours and a long acting stimulant for about 8 -12 hours. Effective 11/20/13 Psychotropic Medications 67

Antidepressants are used in children to treat symptoms of depression and other conditions. Symptoms of depression may include: o Feelings of hopelessness or helplessness o Loss of energy o Changes in appetite o Weight gain or weight loss o Not being able to enjoy activities the child used to enjoy o Thoughts of suicide Effective 11/20/13 Antidepressants may help with other conditions: o School phobias o Panic attacks o Eating disorders o Autism o ADHD o Bedwetting o Anxiety disorders o Obsessive-compulsive disorder (OCD) o Post-traumatic stress disorders (PTSD) o Personality disorders o Sleeping problems Psychotropic Medications 68

Antidepressants: SSRIs Selective Serotonin Reuptake Inhibitors (SSRIs) are one of the newer groups of antidepressants. SSRIs are often used to treat depression and other disorders in children. SSRIs are often used because they are safer than some of the older antidepressants if overdose occurs. Effective 11/20/13 Examples are: o Citalopram (Celexa) o Excitalopram (Lexapro) o Fluoxetine (Prozac) o Fluvoxamine (Luvox) o Sertraline (Zoloft) o Paroxetine (Paxil) Psychotropic Medications 69

Possible Side Effects and Adverse Reactions of SSRI Antidepressants Flu-like symptoms: o Headaches o Nausea o Stomach upset o Dry mouth o Extreme sweating Other side effects: o Trouble sleeping o Irritability o Weight changes Warning The caregivers of children taking SSRIs should monitor them for depression that is getting worse and thoughts about suicide. The caregiver or medical consenter should immediately talk to the doctor if this happens. Effective 11/20/13 Psychotropic Medications 70

Antidepressants: SNRIs Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) are usually prescribed when SSRIs have not worked. SNRIs are not usually prescribed to children. However, they may be helpful in some cases. Examples are: o Venlafaxine (Extended Release Effexor XR) o Duloxetine (Cymbalta) o Desevenlafixe (Pristiq) Effective 11/20/13 Psychotropic Medications 71

Possible Side Effects and Adverse Reactions to SNRI Antidepressants Side Effects: o Abnormal dreams o Nervousness o Body weakness o Chills o Cough o Dizziness o Headache o High blood pressure o Increased sweating o Loss of appetite or weight o Stomach or colon problems Effective 11/20/13 Adverse Reactions: o o o Thoughts of suicide Panic attacks Hallucinations Psychotropic Medications 72

Atypical Antidepressants Children who have been traumatized may have problems with sleep. Atypical antidepressants are more often used to help children with sleep problems than to treat depression. These medications are usually safer for children than standard prescription sleep medications (such as Ambien, Halcion, Lunestra, Rozerem, and Sonata). Examples are: o. Bupropion (Wellbutrin) o. Mirtazapine (Remeron) o. Trazadone (Desyrel) Effective 11/20/13 Psychotropic Medications 73

Possible Side Effects and Adverse Reactions of Atypical Antidepressants Side Effects: o Sleepiness o Headache o Constipation o Dry mouth o Agitation o Nervousness o Weight changes o Flushing o Sweating o Tremors o Changes in blood pressure Effective 11/20/13 Adverse Reactions: o Male erection that is unwanted, painful and lasts a long time (Trazadone) o Seizures (Wellbutrin) o Low white blood cell count (Remeron) Psychotropic Medications 74

Other Information About Antidepressants o These medications may take a couple of weeks to work. o A two-week break may be needed after finishing one medication and starting another one. o A child should never stop taking antidepressants suddenly. Your child’s doctor will help you wean the child off of the medication slowly. This will help prevent dizziness and other side effects. Effective 11/20/13 Psychotropic Medications 75

Antipsychotics may be used to treat a number of conditions in children: o Psychosis o Bipolar disorder o Schizophrenia o Autism o Tourette’s syndrome o Severe aggression Antipsychotics are divided into two groups: o Atypical (or second generation) antipsychotics, were first developed in 1994. o Typical (or first generation) antipsychotics were first developed in 1950. Effective 11/20/13 Psychotropic Medications 76

Atypical (Second Generation) Antipsychotics Atypical antipsychotics are the most common antipsychotics used in children. These antipsychotics are less likely to cause movement disorders (shuffling walk, tongue sticking out of mouth, drooling, etc. ) than the typical antipsychotics. Examples are: o Aripiprazole (Abilify)* o Quetiapine (Seroquel)* o Olanzapine (Zyprexa) o Risperidone (Risperdal) o Clozapine (Clozaril, Fazaclo)* o Ziprasidone (Geodon) o Paliperidone (Invega) o Iloperidone (Fanapt) o Asenapine (Saphris) o Lurasidone (Latuda) Effective 11/20/13 Psychotropic Medications *The Physician Desk Reference has a black box warning for Abilify, Seroquel and Clozapine. 77

Black Box Warning for Abilify and Seroquel The Physician Desk Reference documents the black box warning for Abilify and Seroquel: o “Not approved for depression in under age 18. Increased the risk of suicidal thinking and behavior in short-term studies in children and adolescents with major depressive disorder and other psychiatric disorders” Effective 11/20/13 Psychotropic Medications 78

Black Box Warning for Clozapine The Physician Desk Reference documents the black box warning for Clozapine: o o Risk of life threatening agranulocytosis Seizures Myocarditis Other adverse cardiovascular and respiratory effects Effective 11/20/13 Psychotropic Medications 79

Possible Side Effects of Atypical Antipsychotics Common Side Effects: o Sleepiness or tiredness o Dizziness o Constipation o Dry mouth o Blurred vision o Difficulty urinating o Sensitivity to lights o Weight gain o Change in menstrual cycle Effective 11/20/13 Less Common Side Effects: o Dytonia: muscle spasms; stiff neck; tongue sticking out of mouth; trouble swallowing o Akathisia: restlessness, unable to sit still o Akinesia: rigid muscles; shuffling walk; drooling; tremor Psychotropic Medications 80

Possible Adverse Reactions of Atypical Antipsychotics o o o Tardive dyskinesia (permanent involuntary movements of tongue, mouth, face, trunk, arms and legs that are more common with typical antipsychotics than with atypical) Overheating or heatstroke (prevent by drinking water and staying out of heat) Metabolic Syndrome (excess weight gain, increased blood pressure, high blood sugar and triglyceride levels) Type II Diabetes, Heart Disease, and Stroke Neuroleptic malignant syndrome (extreme muscle stiffness, high fever, sweating, tremors, confusion, unstable blood pressure and heart rate). This is a medical emergency. Clozaril: o o o Can cause a dangerous drop in white blood cells Requires weekly blood work for 6 months, every 2 weeks for the next 6 months and then every 4 weeks thereafter Usually used only when other treatments fail Effective 11/20/13 Psychotropic Medications 81

Typical (First Generation) Antipsychotics Typical antipsychotics are used less often in children. Examples are: o Chlorpromazine (Thorazine) o Haloperidol (Haldol) o Perphenazine (Trilafon) o Pimozide (Orap) Effective 11/20/13 Psychotropic Medications 82

Other Information About Antipsychotics o Each child is different, so a child may need to try different medications in order to find the one that works best. o You should start seeing positive changes in 2 -3 weeks, but it may take 6 -8 weeks. o A child should never stop taking an antipsychotic suddenly. This may cause fast changes in mood, agitation, aggression, nausea, sweating or tremors. The child’s doctor will help you wean the child off the medication slowly. o The child’s weight, glucose levels and lipid levels should be monitored regularly by a doctor while taking antipsychotic medication. Effective 11/20/13 Psychotropic Medications 83

Mood Stabilizers Mood stabilizers are used to treat children with mood disorders, such as bipolar disorder. Children with bipolar disorder have extreme mood swings (manic or depressed states). n When children are in the “manic” state, they may be n very active, talk too much, have a lot of energy, and sleep very little. They may also be angry, irritable, or feel overly self-important. Children in the “depressed” state may: o o o Feel hopeless or helpless. Have a loss of energy. Have changes in appetite. Gain or lose weight. Not enjoy activities the child used to enjoy. Have thoughts of suicide. Effective 11/20/13 Psychotropic Medications 84

Mood Stabilizers Some medications used to treat mood disorders are also used to treat seizure disorders. If it is used to treat seizures, it is not considered a psychotropic medication. Medications that may be used to treat mood or seizures: o Lamotrigine (Lamictal) o Divalproex (Depakote) o Carbamazepine (Carbatrol, Tegretol XR) Effective 11/20/13 Medications that are only used as mood stabilizers: o Lithium (Eskalith, Eskalith CR. Lithobid) Psychotropic Medications 85

Possible Side Effects and Adverse Reactions of Lamotrigine (Lamictal) Side Effects: o Dizziness o Problems sleeping o Drowsiness o Blurred vision o Vomiting o Constipation o Stomach aches Adverse Reactions: o Serious rashes o Stevens Johnson Syndrome* * Stevens Johnson Syndrome is a rare, but serious condition affecting the skin and mucous membranes. It is a medical emergency that requires hospitalization. It begins with swelling of the face and tongue, skin pain, blisters, hives, shedding of skin; the child may also have fever, sore throat, burning eyes, cough. Immediately contact the doctor if your child develops a rash while taking this medication. Effective 11/20/13 Psychotropic Medications 86

Possible Side Effects and Adverse Reactions of Divalproex (Depakote) Side Effects: Indigestion Nausea/vomiting Drowsiness Hair loss Weight changes Changes in menstrual cycles o Constipation o o o Adverse Reactions: o Liver toxicity and liver failure (very rare but very serious) Children taking Depakote should have regular blood work to check for liver problems and make sure the dose is safe and effective Effective 11/20/13 Psychotropic Medications 87

Possible Side Effects and Adverse Reactions of Carbamazine (Tegretol) Side Effects: o Dizziness o Drowsiness o Nausea o Unsteadiness o Vomiting Adverse Reactions: o Reduction of blood cell production in the bone marrow o Decreased red blood cells, white blood cells, and platelets o Stevens Johnson Syndrome* Children should have regular blood work to rule out decreased blood cells. Contact the doctor right way if the child has tiredness, weakness, easy bruising or unusual bleeding. *See previous slide on Lamictal regarding Stevens Johnson Syndrome Effective 11/20/13 Psychotropic Medications 88

Possible Side Effects and Adverse Reactions of Lithium Side Effects: o Fatigue o Muscle weakness o Nausea o Stomach cramps o Weight gain o Urinating more often o Slight hand tremor o More thirsty o Low blood sugar o Lower thyroid function o Hair loss Adverse Reactions: These are signs of Lithium toxicity: o Repeated vomiting/diarrhea o Severe tremors o Difficulty walking/unable to walk o Poor coordination o Extreme sleepiness o Slurred speech/difficulty sleeping o Blurred vision/ringing in ears o Unable to control eyes going in circles o Muscle twitching o Seizures Children taking Lithium should have regular blood work to determine if the blood level of Lithium is in the safe and effective range. Effective 11/20/13 Psychotropic Medications 89

Other Information About Mood Stabilizers o Mood stabilizers may effect the metabolism, liver, kidneys, and thyroid. o Children taking Tegretol, Depakote or Lithium should have routine blood work. Levels are usually checked in the morning before the medication is given to the child. Effective 11/20/13 Psychotropic Medications 90

Antianxiety agents (Tranquilizers) Tranquilizers are used to treat people with severe anxiety that interferes with their daily activities. The Benzodiazepines are potentially addictive and are more commonly used in the hospital. However, they may be used to treat neurological problems in children, such as muscle spasms. Examples are: Benzodiazepines: o Clonazepam (Klonopin) o Lorazepam (Ativan) o Alprazolam (Xanax) Effective 11/20/13 Other (not addictive) o Buspirone (Buspar) Psychotropic Medications 91

Summary o o o The vast majority of children in DFPS conservatorship do not need psychotropic medications. Some children need psychotropic medications to get temporary relief from symptoms of trauma from abuse, neglect or separation to treat behavioral health disorders. The medical consenter must decide whether or not to give consent before a doctor can start a child on psychotropic medications. Psychotropic medications alone are not the best treatment. They should always be used with non-pharmacological interventions, such as behavior interventions and behavioral health therapy, for long-lasting effects. The caregiver/medical consenter has a responsibility to monitor the child to make sure the medication is helping, watch the child for side effects and adverse reactions, and let the doctor and CPS know how the child is doing. CPS staff, the caregiver, or the medical consenter should contact STAR Health if they believe the child is taking medications outside the Psychotropic Medication Utilization Parameters. Effective 11/20/13 Psychotropic Medications 92