Psychiatric Medications and Child Welfare

1. Psychiatric Medications andChild Welfare Terry Lee, MD drterry@uw.edu UW School of Medicine Department of Psychiatry Developmentally-Informed Representation of Young Children in Child Welfare October 16, 2015

2. Overview • Psychiatry resources • Child welfare and psychiatric medications: appropriate or inappropriate? • Bench card • Questions to ask psychiatrists • What some other states are doing

3. Psychiatry Resources • aacap.org: American Academy of Child and Adolescent Psychiatry (AACAP)—main child psychiatry organization • Facts for Families • Practice Parameters • cebc4cw.org: California Evidence-Based Clearinghouse for Child Welfare—CW resources, rating scales, assessment tools, webinars, resources • nlm.nih.gov/medlineplus/: Medline Plus—medication information • ohiomindsmatter.org: Ohio Minds Matter—online toolkit for consumers and stakeholders to improve psychiatric prescribing to young people

4. Youth in the Child Welfare System and Mental Health Needs/Psychiatric Medications

5. National Data • Youth in foster care prescribed psychiatric medications at 2-10 times the rate of non-foster youth on Medicaid (MMDLN, 2010; Raghavan, 2005; Zito, 2008) • Any psychiatric medication • Multiple psychiatric medications at the same time • Children < 5 years old

6. Stakeholder Concerns About Psychiatric Medications in Child Welfare (McMillen, 2006) • Evaluations and follow-ups are too short • Too quick to put kids on meds • Too many kids on meds • Too many meds prescribed • Doses are too high • Kids turned into “zombies”

7. Factors Contributing to Increased Prescribing of Psychiatric Medications to Youth Involved with the Child Welfare System

8. Causes: Good Reasons for Increased Prescribing • Youth involved with child welfare system have higher rates of MH needs: • Maltreatment/trauma • Removal from home, family, and ecology • Multiple placements, disrupted attachments • Poverty • Intrauterine exposures, genetic risks • Entry into foster care also: • Provides access to Medicaid • Systematic screening for behavioral health needs • Advocacy for behavioral health needs

9. Factors Potentially Contributing to Inappropriate Psychotropic Prescribing • Insufficient time for proper assessment • Limited information on youth history and current functioning • Poor continuity of care • Lack of critical clinical feedback to inform psychiatrist decision-making • Ineffective advocacy

10. Factors Potentially Contributing to Inappropriate Psychotropic Prescribing • Unrealistic hopes that medication will stabilize a complex psychosocial situation • Under-recognition of trauma etiology in formulating complex presentations • Lack of commitment of resources to parent skills training, especially if permanency is unclear

11. Factors Potentially Contributing to Inappropriate Psychotropic Prescribing • Limited access to effective psychosocial interventions • Limited access to effective psychiatric prescribing practices • Limited integration of psychiatric and psychosocial treatments

12. Evidence of Unmet or Underserved Mental Health Needs Too

13. LA County CW Youth, Psychotropics and MH Needs (Zima, 1999a & 1999b) • Foster youth 6-12 years-old • 49% of youth diagnosed with ADHD had not received psychotropics in the previous year • 80% of youth identified with severe psychiatric disorder not recommended for medication evaluation in previous year

14. National Survey of Child and Adolescent Well-Being (NSCAW) • National longitudinal survey • Youth and families referred to child welfare • Completed investigations • Two groups of children (0-14 years-old) randomly chosen between October 1999 and December 2000 • 5,504 youth entering the system • 727 youth in out-of-home placement>12 months • Evaluated at baseline and 12 months • Child Behavior Check List

15. NSCAW 2-14 Years-Old (Burns, 2004) • 47.9% of youth scored in the clinical range on the CBCL • 39.3 % of youth in kinship care • Youth with strong evidence of mental health need (CBCL) were more likely to receive help, but only ¼ had received any care in the previous 12 months • Factors relating to increased likelihood of services: • Preschoolers: sexual abuse (versus neglect) • Elementary school age: Caucasian and living out-of-home • Adolescents: out-of-home and parent with severe mental illness

16. NSCAW <6 Years-Old (Stahmer, 2005) • Assessed 5 domains: cognition, behavior, communication, social skills and adaptive functioning • Developmental and/or behavioral health needs: • Toddlers (0-2 years-old): 41.8% • Preschoolers (3-5 years-old): 68.1% • Youth with need receiving services: 22.7% • Factors relating to decreased likelihood of services: • Remaining at home • 0-2 years-old

17. NSCAW II (Horwitz, 2012) • Children 12-36 months old with behavioral health needs • Only 19.2% received any type of behavioral health service, including parent skills training related to mental health problems

18. NSCAW Out-of-Home for ~1 Year (Leslie, 2004) • Youth 2-15 years-old • Need defined by CBCL clinical range: 46.8% of youth • 75.8 % had accessed outpatient mental health services, 24.2% had not received services • Predictors of receiving services: higher CBCL scores, older age, history of sexual abuse • Lesser use of services: history of neglect, African-American race/ethnicity

19. Youth at Risk for Underserved Mental Health Needs • African-American youth • Victims of neglect • Youth remaining at home or placed in kinship care • Utilize systematic screening!

20. Psychiatric Medication Bench Card • Help courts ask the right questions • Help child welfare workers prepare and have specific information in court • Mental health system and child psychiatrists are still responsible for providing good mental health and psychiatric care • But court can provide oversight and advocacy

21. Some Possible Questions to ask a Child Psychiatrist

22. Questions to Ask About Psychiatric Medications (Adapted from Facts for Families, AACAP, 2004) • How was the diagnosis made? Did you use information from other informants, like the school? • What is known about how helpful this medication is for other children who have a similar condition to my child’s? • How will the medication help my child? How long before I see improvement? When will it work? • What are the side effects that commonly occur with this medication? • Are there any serious side effects? • Is this medication addictive? Can it be abused?

23. Questions to Ask About Psychiatric Medications (Adapted from Facts for Families, AACAP, 2004) • Who will be monitoring my child’s response to medication and make dosage changes if necessary? How often will progress be checked and by whom? • Are there any other medications or foods which my child should avoid while taking the medication? • Are there interactions between this medication and other medications (prescription and/or over-the-counter) my child is taking?

24. Questions to Ask About Psychiatric Medications (Facts for Families, AACAP, 2004) • Are there any activities that my child should avoid while taking the medication? Are any precautions recommended for other activities? • How long will my child need to take this medication? How will the decision be made to stop this medication? • What do I do if a problem develops (e.g. if my child becomes ill, doses are missed or side effects develop)?

25. Questions to Ask About Psychiatric Medications (Adapted from Facts for Families, AACAP, 2004) • What is the cost of the medication (generic versus brand name)? • Are there any psychosocial (non-medication) treatments that can help? How do they compare to medication treatments?

26. Consider Psychiatric Medication Benefitrelative to Risk

27. Psychiatric Medication Classes

28. Stimulant Positive Effects • Very effective for ADHD, including long term • Relatively rapid onset of action • On-task behavior by all raters • Compliance as rated by teachers • Peer nominated rankings of social standing • Parent-child interactions • Attention during sports activities • Performance on paper-and-pencil and computerized tests of attention, math, short-term memory tasks, problem-solving, accuracy

29. Stimulant Negative Effects • Appetite suppression • Sleep disturbance • Elevated pulse and blood pressure • Tics • Obsessive-compulsive behavior • Loss of spontaneity • Abuse potential • More tightly controlled prescribing (Schedule II medication) • Long term • Shorter height • Lighter weight

30. Stimulant Diversion (Wilens, 2008) • Took stimulants without prescription • 5-9% of elementary through high school age • 5-35% of college age individuals • 16-29% of youth prescribed stimulants who were asked to sell, give or trade their stimulants • Cognitive enhancers? E.g. NY Times 4/18/15: “Workers Seeking Productivity in a Pill Are Abusing ADHD Drugs”

31. Stimulants • Concerta (OROS-methylphenidate) • Adderall XR (mixed amphetamine salts extended release) • Dexedrine Spansules (dextroamphetamine spansules) • Ritalin LA, SR (methylphendiate) • Metadate (methylphenidate) • Focalin XR (dex-methylphenidate extended release)—isomer that provides most of the positive effect

32. Relatively Newer Long-Acting Stimulants • Quillavent XR: long-acting liquid methylphenidate • Daytrana (methylphenidate transdermal patch) • Take off to stop action at some point • Can be taken off and • reattached (on someone else?) • Extract methylphenidate ? • To deliver 30 mg, 82.5 mg in patch • Vyvanse (lisdexamfetamine)-prodrug: • must be ingested to activate –less likely to be diverted and ingested by alternate route (snorting or injecting)? • not any more effective • Aptensio XR (methylphenidate MLR)-long-acting (12 hours) formulation

33. Washington State Medicaid Second Opinion Dose Thresholds (>4 yo) • Methylphenidate total dose > 120 mg/24 hours • Amphetamine total dose > 60 mg/24 hours • Lisdexamfetamine total dose > 70 mg/24 hours

34. Non-Stimulant Medications for ADHD • Atomoxetine (Strattera)* • Alpha Agonists—primarily treat hyperactivity • Guanfacine XR (Intuniv)* • Clonidine XR (Kapvay)* • Guanfacine(Tenex) • Clonidine (Catapress) • Buproprion (Wellbutrin) • Modafinil (Provigil) • Imipramine • *FDA-approved for ADHD

35. Atomoxetine for ADHD • Atomoxetine (Strattera) not as effective as stimulants • Pros • Effective throughout the day? • Not Schedule II medication • No increase in tics • Less sleep disruption and appetite suppression

36. Atomoxetine for ADHD • Cons • FDA black box warning for suicidal ideation • Rare, severe liver injury • Very rare sudden cardiac death at therapeutic doses • Increase blood pressure and pulse—less than stimulants • Weight loss—less than stimulants • Effects on growth? • Nausea and vomiting • Headache • Sedation • Lightheadedness and dizziness

37. Positive Effects of Alpha-Agonists for ADHD • Helps decrease hyperactivity • Support for adding to stimulants for further effect • Decreases tics • Helps with sleep (sedating)

38. Negative Effects of Alpha-Agonists for ADHD • Sedating • Dizziness upon standing • Lower blood pressure and pulse • Tolerance develops to above 3 bullets • Rebound hypertension if stopped suddenly

39. Some Specific Serotonin Reuptake Inhibitors (SSRIs) • Fluoxetine (Prozac) • Sertraline (Zoloft) • Citalopram (Celexa) • Paroxetine (Paxil) • Escitalopram (Lexapro)

40. Number Needed to Treat (NNT) • Goes beyond “statistical significance” • The number of patients who must receive the treatment to get a response that is attributable to active treatment • More effective treatments will have a lower NNT

41. Specific Serotonin Reuptake Inhibitors (SSRIs) • Meta-analysis of SSRI NNT for youth disorders (Bridge, et al; 2007) • Anxiety disorders (adjusted): 4 (95% CI 3-6) • Depression: 10 (95% CI 7-15) • OCD: 6 (95% 4-8) • (for comparison, stimulant for ADHD NNT typically range from 1.5-3) • Effective for youth PTSD?

42. Specific Serotonin Reuptake Inhibitors (SSRIs) • Negative Effects • Slight increase in suicidal ideation, especially for youth with depression: 2%? • Induce mania? If youth has bipolar disorder • Activation, insomnia or irritability—usually transient • Sedation • Gastrointestinal symptoms • Headache • Increased bleeding risk—less common • Apathy—sometimes a sign of too high a dose • Decreased libido—rare in adolescents

43. Lithium Carbonate (LiCO3) • Positive effects • Effective for classic bipolar disorder • Mild short term positive effects for other disorders • Negative effects • Weight gain • Acne • Sedation—may be transient • Tremor—may be transient • Increased thirst • Depressed thyroid function, which may lead to hypothyroidism • Kidney effects, usually insignificant

44. Divalproex (Depakote) • Positive Effects • Anti-seizure medication • Effective in classic or “real” bipolar disorder—the type seen in adults and post-pubertal youth • Mild positive effects on (controversial) pediatric bipolar disorder

45. Divalproex (Depakote) • Serious Negative Effects • Hormone-like effects, including increased rate of Polycystic Ovaries in females • Neural Tube Defects increased in children of women taking Depakote during pregnancy • Serious but rare • Hepatoxicity-potentially fatal liver damage • Pancreatitis-potentially fatal (~2 per 1,000 patient years) • Severe bone marrow suppression • Withdrawal seizures if stopped suddenly

46. Divalproex (Depakote) • Negative Effects • Common—usually temporary • Nausea • Sedation • Dizziness • Weight gain • Vomiting • Weakness • Gastrointestinal symptoms • Rash • Mild elevation of liver enzymes • Mild suppression of bone marrow function, such as platelet function, which can lead to easy bruising or nose bleeds

47. Atypical Antipsychotics • Olanzapine (Zyprexa) • Risperidone (Risperdal) • Quetiapine (Seroquel) • Ziprasidone (Geodon) • Aripiprazole (Abilify) • Asenapine (Saphris) • Iloperidone (Fanapt) • Lurasidone (Latuda) • Paliperidone (Invega)

48. Atypical Antipsychotics • Positive Effects • Effective for psychosis • Effective for classic mania and bipolar disorder • Less effective for controversial pediatric bipolar disorder • Moderately effective for tics and Tourette’s Disorder • In the short term, unlikely to have irreversible negative effects

49. Atypical Antipsychotics • Negative Effects • Common • Sedation • Weight gain (depending on which antipsychotic, 9.7-18.7 pounds in ~11 weeks in one study (Correll et al, 2009)) • Dyslipidemias • Glucose intolerance, which may lead to diabetes • Extra-pyramidal side effects (EPS)-muscle stiffness, sometimes with tremor • Akathisia-inner restlessness associated with urge to keep moving • Blurred vision

50. Atypical Antipsychotics • Negative Effects • Less common • Diabetes • Acute dystonia-temporary and non-fatal, but very uncomfortable, muscle spasm when starting antipsychotic medication • Rare but serious • Tardive dyskinesia-irreversible movement disorder • Neuroleptic Malignant Syndrome-muscle rigidity, fever, autonomic instability and altered mental status which, in rare instances, may lead to death