Psychotropic Medication for Children in Texas Foster Care

1. Psychotropic Medication for Children in TexasFoster Care Training for Child Protective Services Staff, Foster Parents and Residential Providers Psychotropic Medications

2. Disclaimers • This training explains the State's expectations for the safe and effective use of psychotropic medications by children in Texas Department of Family and Protective Services (DFPS) conservatorship. Always discuss specific questions about the medications with the child's doctor. • Residential child care providers must have additional training covering: • Their specific policies and procedures on psychotropic medications. • Who may consent to the use of psychotropic medications for children who are not in DFPS conservatorship. Residential Child Care Licensing Minimum StandardsSection 748.885 and Section 749.885 Psychotropic Medications

3. What are psychotropic medications? Psychotropic medications are used to treat emotional and behavioral health symptoms and disorders.  They mostly act on the central nervous system and affect mood, thoughts, behaviors, and how a person processes information and perceives his or her surroundings. Psychotropic Medications

4. Helpful Information and Definitions • Caregiver means a foster parent. • Residential provider means a child placing agency or residential operation or their staff. • The medical consenter is the person named by the court or DFPS to make medical decisions for a child in DFPS conservatorship. • Foster parents or other live-in caregivers are the medical consenters for most children in foster care. • DFPS caseworkers are usually the medical consenters for children living in residential facilities with shift staff (other than emergency shelters). • STAR Health is the health plan for children in DFPS conservatorship. • DFPS conservatorship means the child is in the legal custody of DFPS. Psychotropic Medications

5. Purpose To educate CPS staff, foster parents, and residential providers about psychotropic medications, help them make informed decisions, and monitor children in DFPS conservatorship who are prescribed these medications. Psychotropic Medications

6. Goals & Objectives • Understand that we should try other interventions before psychotropic medications in most cases • Understand the need for a complete psychiatric evaluation prior to giving psychotropic medications • Understand the responsibility of the medical consenter to give informed consent for each psychotropic medication prescribed for a child • Understand how psychotropic medications are used Psychotropic Medications

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

8. Psychotropic Medication Training Module I Decisions About Consenting & Psychiatric Evaluation Psychotropic Medications

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

10. Use of Psychotropic Medications Most children will gradually heal in an appropriate environment and with consistent interventions. But some children need medication to cope with the trauma of abuse or neglect. Other children need medication to treat behavioral health disorders that they inherited or developed, such as Attention Deficit Hyperactivity Disorder (ADHD), severe depression, or psychosis. Psychotropic medications help children feel better and control their symptoms so they can function at home, in school, and in their daily lives. They may need these medications temporarily to treat emotional stress or long-term to treat life-long behavioral health disorders. Psychotropic Medications

11. Most children will gradually heal in an appropriate, stable environment. This means that the child does not change placements and the caregiver: Is patient, understanding, kind, loving, and gentle. Gives clear instructions about expectations and house rules. Gives consistent consequences when rules are broken. Teaches the child coping skills and how to control their behavior and emotions in an age appropriate way. Praises the child for positive behaviors. The Importance of an Appropriate Environment Psychotropic Medications

12. The Importance of an Appropriate Environment Children may act out as they adjust to a new home and learn new rules. Caregivers should expect that adjustment takes time and give appropriate support and acceptance. Over time, most children will learn to trust, feel safe, and learn to control their emotions and behavior in way that is appropriate for their age. Psychotropic Medications

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

14. Other Interventions • Taking a class on behavior intervention or trauma-informed care. Talk to CPS, your CPA, or your residential operation to find out about classes. • Working with the child’s therapist, the school, CPS staff, and others to find interventions that work and make sure everyone is using the same interventions. Consistent interventions and consequences help the child learn to manage his or her behavior and emotions. Psychotropic Medications

15. Seek Medical Help If a child has serious symptoms or is not getting better with other interventions, the caregiver or medical consenter should talk to a doctor. Anytime a child is a danger to himself/herself or others, the caregiver or medical consenter should immediately contact the doctor. Examples include suicidal or violent thoughts or actions. A primary care provider, who is not a psychiatrist, may prescribe psychotropic medications for: • Attention Deficit Hyperactivity Disorder (ADHD). • Mild anxiety. • Mild depression. For more complex problems, the child should see a psychiatrist. The child psychiatrist and adolescent psychiatrist will do a complete psychiatric evaluation and make a recommendation about treatment. Ask the child’s primary care provider if you are not sure if the child needs to see a psychiatrist. Psychotropic Medications

16. Complete Psychiatric Evaluation What the psychiatrist will do: • Talk to the child • Talk to the caregivers and medical consenter • If needed, get laboratory studies such as blood tests or x-rays • If needed, get special assessments such as: • A psychological evaluation which is a mental examination and testing by a psychologist • Educational assessments which help find out a child's ability to learn material at an appropriate age and grade level and the best way for a child to learn • Speech and language evaluation to assess the child’s ability to understand language, express him or herself, and speak clearly • Give a diagnosis • Recommend the best way to treat the child Psychotropic Medications

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

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

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

20. Psychiatrist’s Recommendations The psychiatrist will make a recommendation for treatment, such as therapy or psychotropic medication, after completing the psychiatric evaluation and making a diagnosis. The psychiatrist may recommend psychotropic medication for the child if he or she believes this is the best way to help the child get better so they can function at school, at home, and in his or her daily life. Psychotropic Medications

21. The psychiatrist must obtain “informed consent” from the child’s medical consenter before prescribing a psychotropic medication. This means the doctor must give the medical consenter enough information to decide whether or not to consent for the child to have the medication. The doctor must also allow the medical consenter to ask questions. The process of understanding the risks and benefits of giving the medication to the child is called informed consent. Consenting to Psychotropic Medications Psychotropic Medications

22. Consenting to Psychotropic Medications The medical consenter must give informed consent for each new medication, but not for changes in the dose. However, the medical consenter should always talk to the doctor if he or she has concerns about the dose. If the medical consenter is not a CPS employee, he or she must also let the CPS caseworker or supervisor know about consenting to the medication by the next business day. If the medical consenter is not sure whether to consent to the medication, he or she should discuss his or her concerns with others involved in the case, such as the CPS caseworker, child placing agency staff, or residential operation treatment team. Psychotropic Medications

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

24. Other Questions to Ask the Doctor • What is the name of the medication?  Is it known by other names? • How effective has it been for other children who have a similar condition to my child? • How will the medication help my child?  How long before I see improvement? • What are the side effects that commonly occur with this medication? • Is this medication addictive?  Can it be abused? Psychotropic Medications

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

26. Discuss Psychotropic Medications with Children It is important to talk with the child about taking psychotropic medications. You should: • Talk to the child in a way that the child can understand. • Make sure the child understands why he or she is taking these medications. • Tell the child what he or she can expect from any tests or treatment. • Find out if the child will accept the tests and treatment. Psychotropic Medications

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

28. Psychotropic Medication Training Module 2 Giving Psychotropic Medications, Monitoring, and Follow Up Psychotropic Medications

29. Giving Psychotropic Medications to Children • Remember that psychotropic medications are only one strategy to help the child. The caregiver or residential provider must continue to provide a stable environment and consistent behavior intervention. The child may also need behavior health therapy. • Always read and keep the insert from the pharmacy that comes with each medication. The insert tells you important information such as how to give the medication and side effects. • Store the medication in the original container that came from the pharmacy. Psychotropic Medications

30. More About Giving Psychotropic Medications • Give the medication exactly as prescribed and never more or less unless directed by the doctor. • Never quit giving the medication to the child unless the doctor tells you to quit. • Follow the doctor’s direction for giving the medication. For example, the doctor may tell you to give the medication at a certain time of day or to make sure the child does not eat certain foods. Psychotropic Medications

31. More About Giving Psychotropic Medications • Watch to make sure the child takes the medication. • Never give a child a medication that is prescribed for someone else. • Keep a medication log for each child. Write down the date, time, and who gave the medication to the child. (Residential Child Care Licensing Minimum Standards Section 748.2151 and Section 749.1541) • Coordinate with the doctor to make sure you get refills on time. • Some psychotropic medications require weaning off gradually. Always follow the doctor’s instructions when stopping medications. Psychotropic Medications

32. What Are Side Effects? • Uncomfortable effects such as stomach aches, drowsiness, dizziness, sleep problems, tremors, and weight gain that usually get better over time • Usually occur when starting a new medication, increasing the dose, or stopping the medication • May get better with healthy diet and exercise • Child can usually continue taking the medication unless it makes the child very uncomfortable or interferes with functioning Psychotropic Medications

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

34. Side Effects and Adverse Reactions Also see (Residential Child Care Licensing Minimum Standards Section 748.2233 and Section 749.1583 regarding side effects and Section 748.2231 and Section 749.1581 regarding adverse reactions) • Always talk to the child’s doctor anytime you have a concern about how a medication is affecting a child. • Always report adverse reactions to the doctor right away. • Call 911 or immediately take the child to the emergency room if the child is having an adverse reaction that is life threatening. Psychotropic Medications

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

36. Monitoring and Follow Up • Take the child to the doctor who prescribed the medication at least every 3 months. The doctor will evaluate how the child is doing and whether the medication is working. • Participate with the child in each visit with the doctor. • Report side effects, adverse reactions, and how the child is doing on the medication to the child’s CPS caseworker and your child placing agency or residential operation. Psychotropic Medications

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

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

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

40. When Does STAR Health Do a PMUR? STAR Health does a PMUR after children have taken the medications for at least 60 days and they fall outside the Parameters in certain categories. The categories are: • All children under the age of four. • Any child who is taking: • 2 or more stimulant medications. • 2 or more antidepressant medications. • 2 or more atypical antipsychotic medications. • 3 or more mood stabilizers. • Any child with 5 or more psychotropic medications. Psychotropic Medications

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

42. What Happens During a PMUR? When a child’s psychotropic medications fall outside of the Parameters, a STAR Health child and adolescent psychiatrist reviews the child’s medical records and talks to the doctor who prescribed the medication. Sometimes medications are changed. Other times the child keeps taking the medications, even though the medications are outside Parameters because the child’s condition is complex and the medication is helping the child. You may request a PMUR by calling STAR Health Member Services at 1-866-912-6283. You may learn more in the STAR Health Frequently Asked Questions document at http://www.dfps.state.tx.us/Child_Protection/Medical_Services/guide-psychotropic.asp Psychotropic Medications

43. Is it okay for my child to take a medication that does not have FDA approval? The Federal Food and Drug Administration (FDA) regulates medications not doctors. Most medications are approved by the FDA based on research in adults. Eventually research and clinical experience lead to “off label” prescribing for children due to clinical studies and research indicating they are safe and effective. Doctors decide which medications to prescribe to children based on: • What medications have worked for children with similar conditions. • What they learn from research and literature. • What they think is best for each child based on their clinical experience. Psychotropic Medications

44. Psychotropic Medication Training Module 3 Overview of Psychotropic Medications Psychotropic Medications

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

46. Target Symptoms (Behaviors) Psychotropic Medications

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

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

49. Examples of short acting stimulants Dextroamphetamine (Dexedrine, Dextrostat) Methylphenidate (Ritalin, Metadate, Methylin) Amphetamine (Adderall) Dexmethylphenidate (Focalin) Examples of long acting stimulants Amphetamine (Adderall XR) Lisdexamfetamine (Vyvance) Methylphenidate (Concerta) Dexmethylphenidate (Focalin XR) Stimulants Psychotropic Medications

50. Side Effects Decreased appetite Weight loss Headaches Stomachaches Trouble getting to sleep Jitteriness Social withdrawal Adverse Reactions Sudden death in children with pre-existing serious heart problems High blood pressure Problems with growing Possible Side Effects and Adverse Reactions of Stimulants Psychotropic Medications