Version1.0|2017
PsychotropicMedicationinFosterCare
TraineeGuide
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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
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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
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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.
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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.
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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.
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Agenda
Segment1 WelcomeandIntroductions
Segment2 LawsandRegulations
Segment3 CourtProcessandForms
BREAK
Segment4 Trauma
Segment5 AccessingServices
LUNCH
Segment6 PsychotropicMedication
BREAK
Segment7 UsingtheCaliforniaGuidelines
Segment8 Wrap-UpandEvaluations
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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.
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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.
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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
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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.
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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
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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)
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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
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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.
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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.
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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.
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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.
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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
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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
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• 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
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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
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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
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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.
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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
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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
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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
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Mental/BehavioralHealthServicesBrainstormingFormCountyorAgency:
RoleinMental/BehavioralHealthforfosterchildren:
CountyMHPProvider’sNameandContactInfo:OtherUsefulPartners’NamesandContactInfo:Agencystrengthsandresources:
Strengthsandresourcesoutsidetheagency:
Whatgaps/needsareleftafterconsideringthesestrengthsandresources?
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Whatinformaltreatmentoptionsareavailabletochildrenandyouthservedbyyouragency?
Aretheseoptionsculturallysensitive?Safeforpotentiallytraumatizedchildren?Diverse?
Whatinformaltreatmentoptionsdoyouwishyouhadaccesstoforyourchildrenandyouth?
Whatformaltreatmentoptionsareavailabletochildrenandyouthservedbyyouragency?
Aretheseoptionsculturallysensitive?Trauma-informed?Diverse?
Whatformaltreatmentoptionsdoyouwishyouhadaccesstoforyourchildrenandyouth?
Whatcanyoudotoincreasethequalityanddiversityoftreatmentoptions?Whocanyouasktohelpdevelopneededresources/services?Canyoupartnerwithanotheragency/entityalreadyengagedinthiswork?Whatisyournextstep?
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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.
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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.
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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.
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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
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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.
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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.
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• 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
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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.
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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
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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,
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• 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.
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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
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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?
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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.
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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
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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
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