Coordinating Mental Health and Child Welfare Services:

1. Coordinating Mental Health and Child Welfare Services: Psychiatric Diagnoses and Use of Psychotropic Medications among Youth in Foster Care Lisa Townsend, Ph.D. Assistant Professor, Rutgers University School of Social Work and Center for Education and Research on Mental Health Therapeutics Jerry Floersch, Ph.D. and Jeffrey Longhofer, Ph.D. Associate Professors, Rutgers University School of Social Work

2. Mental Health Treatment is Highly Relevant to the Provision of Child Welfare Services • Psychotropic medications are prescribed to youth in foster care at greater rates than for non-foster youth. (Zito, Safer, Sai, Gardner, Thomas, & Coombes, et al., 2008; Rubin, Feudtner, Localio, & Mandell, 2009) • Higher rates of mental health disorders are found in foster youth than in non-foster youth. (dos Reis, Zito, Safer, & Soeken, 2001) • Foster youth have more mental health claims, more psychiatric hospitalizations, and more mental health expenditures than children on Medicaid for reasons other than abuse/neglect. (Harman, Childs, & Kelleher, 2000)

3. Mental Health Disorders, Youth Outcomes, and Medication • Youth with mental health disorders and foster youth are disproportionately represented in juvenile justice (Maschi, Hatcher, Schwalbe, & Scotto Rosato, 2008) • Mental health disorders are linked with more frequent placement disruptions (Fowler, Toro, & Miles, 2009) • Mental health disorders are linked with repeat use of crisis services (Park, Mandell, & Lyons, 2009) • Mental health disorders are associated with decreased likelihood of permanent placement (Courtney & Dworsky, 2006)

4. Comparative Rates of Mental Health Diagnoses: 45 States vs. New Jersey (Medicaid Claims in Year 2004)(45-state data: Townsend, Gerhard, Huang, Scotto Rosato, Akincigil, & Crystal, under review)N=409,369 (45-states); N=9,053 (NJ)

5. Comparative Rates of Psychotropic Prescriptions: 45 States vs. New Jersey (Medicaid Claims in Year 2004)(45-state data: Townsend, Gerhard, Huang, Scotto Rosato, Akincigil, & Crystal, under review)

6. Issues Related to Oversight of Psychiatric Medication in Child Welfare (Naylor, Davidson, Ortega-Piron, Bass, Gutierrez, & Hall, 2007) • Youth in state care do not always have a consistent advocate to follow their psychiatric medication history • States have different systems in place to provide consent for psychiatric medication and to monitor their use in foster children. Consent may be provided by: • legal guardians (foster parents, caseworkers) • adjudication by a judge

7. Inconsistent Access to Mental Health Treatment • Youth who present with elevated levels of internalizing or externalizing emotional/behavioral symptoms are more likely to receive psychotropic medications (Raghavan, Zima, Andersen, Leibowitz, Schuster, & Landsverk, 2005) • As many as 75% of youth with clinically significant emotional/behavioral symptoms had not received mental health services during the previous 12 months (Burns, Phillips, Wagner, Barth, Kolko, & Campbell, et al., 2004) • Half of older youth (17+) in residential treatment have not received prior outpatient services (McMillen, Scott, Zima, Ollie, Munson, & Spitznagel, 2004) • Presence of behavioral health carve-outs may restrict access to mental health services for youth in foster care (Raghavan, Leibowitz, Andersen, Zima, Schuster, & Landsverk, 2006) • Evidence-based psychosocial services are not consistently available (Landsverk, Burns, Stambaugh, & Rolls Reutz, 2009)

8. Placement Setting is Associated with Varied Rates of Mental Health Service Use • Kinship care is associated with reduced access to mental health services (Leslie, Landsverk, Ezzet-Lofstrom, Tschann, & Slymen, et al., 2000) • Remaining in the parental home is linked with decreased likelihood of receiving mental health services (Burns, Phillips, Wagner, Barth, Kolko, & Campbell, et al., 2004) • Youth in foster care group homes received more restrictive mental health services (ER visit, remand to detention facility, attending a special school) than youth in therapeutic foster care settings (Breland-Noble, Farmer, Dubs, Potter, & Burns, 2005).

9. Greater Use of Psychiatric Medications is Found in Residential or Specialty Placement Settings(Baker, Archer, & Curtis, 2007: The Odyssey Project) • Youth in residential foster care (RTC) have greater levels of mental health symptoms (measured by the CBCL) than youth in therapeutic foster care (TFC) • 40% of youth entering RTC/TFC have histories of criminal activity, 40% have had prior psychiatric hospitalizations; 33% have histories of substance abuse and suicidal ideation; 10% have histories of sexual perpetration • 82% of youth entering RTC/TFC are taking at least 1 psychotropic medication, and 29% are taking antipsychotics • Youth in RFC are significantly more likely to be on an antipsychotic medication at admission than youth in TFC

10. Type of Maltreatment is Linked with Prescription of Psychiatric Medications • Youth who enter the child welfare system as a result of physical or sexual abuse have a greater likelihood of receiving psychotropic medications than youth who have experienced neglect (Raghavan, Zima, Andersen, Leibowitz, Schuster, & Landsverk, 2005)

11. Standards for Assessment and Treatment of Mental Health Conditions among Foster Youth • American Academy of Pediatrics • Pediatricians should be involved in service planning • All foster youth should receive a comprehensive physical, dental, developmental, and mental health evaluation • Health status should be routinely monitored throughout placement

12. Standards for Assessment and Treatment of Mental Health Conditions among Foster Youth • Child Welfare League of America (Crismon, 2009) • All youth in foster care should receive a mental health assessment • A DSM-IV diagnosis should be present before psychiatric medications are prescribed • Psychiatric medication treatment should be combined with psychotherapy • Target symptoms and treatment goals in relation to medication should be clearly defined • Progress should be assessed at every medication visit with child and caregiver • The child and caregiver should be educated about all treatment options, what to expect from treatment, and possible side effects of medication • Side effects should be documented at each medication visit • Height, weight, blood pressure, and appropriate laboratory indicators should be monitored routinely • One medication per disorder should be tried initially rather than multiple medications • Medications for aggression should be tapered if target symptoms are eliminated for six months

13. Standards for Assessment and Treatment of Mental Health Conditions among Foster Youth • American Academy of Child and Adolescent Psychiatry • The child’s view of his/her mental health symptoms should be incorporated into treatment • The impact of placement transitions on mental health should be considered • Children should receive mental health assessments at foster care entry and throughout placement, not only when behavioral crises occur • Foster parents should be informed about a child’s mental health symptoms and receive education/training regarding how to meet his/her needs • Information-sharing between agencies should be promoted • Pre-and post-transition coordination of service changes should be a priority • Children should participate in their treatment planning according to their individual abilities to do so

14. Barriers to Coordination of Mental Health and Child Welfare Services • Placement disruptions (Raghavan, Inkelas, Franke, & Halfon, 2007) • Under-reporting of mental health symptoms by all parties involved with youth (Raghavan, Inkelas, Frankes, & Halfon, 2007) • Lack of a shared language between psychiatry and child welfare professionals (McMillen, Fedoravicius, Rowe, Zima, & Ware, 2007) • Separate mental health and child welfare information management systems (Annie E.Casey, Workgroup, October, 2009)

15. Suggestions for Improving Coordination of Services at the Provider Level Townsend, Groza, & Crystal, 2010 • Use multiple sources of information for reporting child mental health concerns • Child welfare workers, foster parents, biological family, teachers • Separate the impact of placement transitions/disruption of routine from response to pharmacological or psychosocial treatment • Re-assess youths’ mental health status immediately following a placement transition • Use standardized symptom scales when possible to augment anecdotal reports of behavior • Adopt the use of a “mental health passport” that documents medications tried, dosage, side effects, and effectiveness

16. Managing Aggressive Behavior • Aggression can be a form of “defensive coping” (Ford, Chapman, Mack, & Pearson, 2006) • Learned response to deal with ongoing threats to safety • Offsets further threat by making others hesitant to interact with the child • “Reactive” rather than pre-meditated/goal-oriented • Affective/impulsive aggression is a key target for psychosocial and pharmacological intervention (Findling, 2008)

17. Consensus Guidelines: Treatment of Recommendations for the Use of Antipsychotics in Youth Pappadopulos, MacIntyre, Crismon, Findling, Malone, & Derivan, et al., 2003 • Begin with a thorough mental health evaluation • Treat underlying disorders (such as PTSD or depression) first • Initial treatment of aggression should focus on educational or psychosocial interventions • Attempt to manage emotional/behavioral crises with psychosocial crisis intervention before relying on emergency use of medications • If medications are needed to manage aggression, try an atypical antipsychotic first, allowing adequate time to determine its effectiveness • Routinely assess side effects and behavioral response • Reduce or eliminate medication if behavioral problems disappear for a minimum of 6 months

18. Specific Medication Issues: Weight Gain Associated with Antipsychotics • Antipsychotic medications are associated with increased risk of weight gain, insulin resistance, and elevated cholesterol in adults (American Diabetes Association/American Psychiatric Association, 2004) • They are also associated with weight gain in adolescents (Correll & Carlson, 2006; Correl, Manu, & Olshankskiy, 2009) • Strategies for reducing weight gain: (Correll & Carlson, 2006) • Monitoring rate of weight gain (4 weeks after starting/switching, quarterly thereafter) • Good dietary choices • Exercise

19. Take-Home Messages from the Research Literature • Pay special attention to the mental health service needs of foster youth who: • live in kinship care or remain in the biological home • have never had a mental health assessment • live in residential or therapeutic foster care settings • have been physically/sexually abused • have transitioned recently (homes and/or providers) • are not receiving psychotherapy • are taking multiple medications (What is the diagnostic rationale? Are side effects being monitored?) **Some youth are not receiving needed mental health services; others do receive treatment that should be monitored and evaluated for effectiveness.**

20. Toward a Psychosocial Intervention for Youth Prescribed Psychiatric Medication • A Framework for Modeling Medication Experience • A Tool for Mapping Youth Medication Experience • First, What is a medication narrative? • Second, Listening to the narrative • Finally, Mapping the narrative

22. What is a Medication Narrative? • What Problem is Medication Solving? • What are the effects? • What is the hoped for future?

23. Emotional (N= 275 quotations) I just wondered why like I’m always angry? Why am I like always sad and depressed? I mean stuff like that. I was thinking there’s something wrong with me in a way. (ID 0002) Behavioral (N = 326 quotations) Yeah, because I’m hyper and I eat too much sugar and I’ll stay up all night sometimes, and my mom says, “Take your pills.” (0042)

24. Diagnosis (N =148 quotations) Well they diagnosed it as bipolar, and they also diagnosed it as depression, or like they’re not exactly sure if I actually have those things right now, because it’s kind of like up in the air because some of the symptoms I don’t show anymore. But so pretty much I think bipolar is what they diagnosed me with, but a little bit of depression too. (0014) Cognitive (N= 167 quotations) Cause I usually don’t pay attention before I was on it, and now that I’m on it, I get good grades, ‘cause I pay attention more. (0025)

25. Body (N= 224 quotations) I visualize it going in my brain and make some reactor go off in my brain and some chemical process comes through. I don’t know, like some shock of chemical. From the commercial they make it seem like those little neurons hit each other or something and they stop missing, cause they say I have a chemical imbalance too, that along with my depression. (0015) Intersubjective (N = 58 quotations) My parents’ happiness. They think I’m happier. The fact that I’m not outraged at everything and that I’m a little nicer to people most of the time. (0023)

26. Three Elements of Medication Experience

27. First, the narrative organizes his perceptions for why he NEEDS medications: • Interviewer: Could you tell me in your own words what was the reason, from your point of view, why you saw her (psychiatrist who prescribes the medication) or why you see her? I see her because I had angry outbursts and ‘cause I had like emotional breakdowns. Like when I get angry, I just go off sometimes, then I’m just like, “Leave me alone. Just leave me alone, just leave me alone.” Can’t nobody talk to me.

28. Next, the adolescent INTERPRETS the medication’s effects: Like instead of feeling I was always in a bad mood, I can like think, but it makes me make better choices, like when I’m mad at somebody, I want to punish them, then I think, “No, I don’t want to do it.” I just leave it alone for right now. . . Like I used to be mad for an hour, and now it only takes me like a couple of seconds to get myself back together. Helps me like to think clearer, take care of myself, like my hygiene, and to do things, like to keep my grades up and things.

29. Third, the adolescent describes the HOPED FOR effects “the medicine makes you think clearer, like If I do this, I might go to… If I rob I store or something, I might go to jail, but if I don’t, I’ll be good.” • Interviewer: What are your thoughts about how things will change with your concerns/diagnosis as you grow older? “Everything will be under control, like my breathing, my anger.”

30. Medication Plot • Comparing oneself before medication, on medication, off medication……. • “Like I used to be mad for an hour, and now it only takes me like a couple of seconds to get myself back together.” • iHop story

31. Medication Narrative • Listen To the Three Elements • Listen For how youth fill in their specific narrative • How? • Mapping the narrative

33. References • Longhofer, J., & Floersch, J. (in press). “Desire and disappointment: Adolescent psychotropic treatment and adherence.” Anthropology & Medicine. •  Floersch, J. Longhofer, J., Kranke, D., & Townsend, L. (online first). Integrating thematic, grounded theory, and narrative analysis: A case study of adolescent psychotropic treatment. Qualitative Social Work, doi:10.1177/1473325010362330, published online 4, March 2010. •  Kranke, D., Floersch, J., Townsend, L., & Munson, M. (online first) Stigma experience among adolescents taking psychiatric medication. Children and Youth Services Review, doi: 10.1016j.childyouth.2009.11.002, published online 3 November 2009.   •  Townsend, L., Floersch, J., & Findling, R. (online first). The conceptual adequacy of the drug attitude inventory for measuring youth attitudes toward psychotropic medications: A mixed methods evaluation. Journal of Mixed Methods Research, doi: 10.1177/1558689809352469, published online first November 2009. •  Floersch, J., Townsend, L., Longhofer, J., Munson, M., Winbush, V., Kranke, D., Faber, R., Thomas, J., Jenkins, J.H., & Findling, R. (2009). Adolescent experience of psychotropic treatment. Transcultural Psychiatry, 46(1), 157-179.  Munson, M. R., Floersch, J., & Townsend, L. (2009). Attitudes toward mental health services and illness perceptions among adolescents with mood disorders. Child Adolescent Social Work Journal, 26: 447–466. •  Townsend, L., Floersch, J., & Findling, R. (2009). Adolescent attitudes toward psychiatric medication: The utility of the Drug Attitude Inventory. Journal of Child Psychology & Psychiatry. Vol. 50 (12), p1523-1531. •  Kranke, D., & Floersch, J.  (2009).  Mental health stigma in schools: Interventions for school social workers.  School Social Work Journal, 34(1), 28-42. •   Floersch, J. (2003). The subjective experience of youth psychotropic treatment. Social Work in Mental Health, 1(4), 51-69. •  Longhofer, J., Floersch, J. & Jenkins, J. (2003). Medication effect interpretation and the social grid of management. Social Work in Mental Health, 1(4), 71-89. •  Longhofer, J., Floersch, J., & Jenkins, J. (2003). The social grid of community medication management. American Journal of Orthopsychiatry, 73(1), 24-34.