Transcript Psychotropic medications and children: science, Law, and Policy

“Psychotropic medications and children:
science, Law, and Policy”
UC Hastings college of law symposium on children’s health, mental
health & the law
March 29, 2014
3/29/14
Bill Grimm
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Federal Focus & Action
Court Resolution & The JV220 Process
State Initiatives
Psychotropic Drug Concerns
Standard of Care
Prioritizing Policies & Actions
Improving Prescribing Practices
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Federal Focus and Action
February 2006:
October 2008:
September 2011:
November 2011:
December 2011:
April 2012:
August 2012:
December 2012:
August 2013:
March 2013:
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Senate Finance Committee Testimony
Federal Fostering Connections to Success and Increasing
Adoptions Act
Child and Family Services Improvement and Innovation Act
Joint Letter from ACF, CMS, SAMHSA, HHS
GAO Report Foster Children
Children’s Bureau Information Memorandum
ACF Because Minds Matter Conference
GAO Report Children’s Mental Health
HHS Office of the Inspector General Investigation
The President’s Budget - $750 million
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Federal Focus and Action
“I think putting me
on all these stupid
meds was the most
idiotic thing I have
ever experienced in
foster care and was
the worst thing
someone could do
to foster kids. I was
upset about my
situation, not
bipolar or ADHD.”
Testimony of Ke’onte
Cooke, 12 year old former
foster child, before
Congress, December 1,
2011
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Court Resolution & The JV220 Process
National Council of Juvenile & Family Court Judges
Resolution
Whereas, Judges in child welfare and juvenile justice cases
are responsible for overseeing the safety and well-being of
children under court jurisdiction;
Whereas, the NCJFCJ believes that this oversight
responsibility extends to children prescribed psychotropic
medications, including ensuring that medications are safe
and appropriate…
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Court Resolution & The JV220 Process
JV-220 Process
•
•
Statute enacted in 1999
Intended to reduce use
of psychotropic drugs
Is the Court Review &
Authorization Process effective?
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COURT RESOLUTION & THE JV220 PROCESS
Percentage of Children in Care Authorized Psychotropic
Medications
2006-2012
17.8
19.4
18.8
18.6
15.8
13.1
13.1
%
%
%
%
%
%
%
JUL20063/29/14
SEP2006
JUL2007SEP2007
JUL2008SEP2008
JUL2009Bill Grimm
SEP2009
JUL2010SEP2010
JUL2011SEP2011
JUL20127
SEP2012
COURT RESOLUTION & THE JV220 PROCESS
Percentage of Children Authorized Psychotropic Medications By Placement Type
Apr-Jun 2013
56
60
50
40
30
20
25
12.7
10
31.1
29.8
22
16
27.3
20
19.5
9.4
19.9 19.4
8.7
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Placement Type
Missing
Other
Trial Home Visit
Runaway
Guardian-Dependent
Transitional Housing
Shelter
Group
Court Specified
FFA
Foster
Kin
Pre-Adopt
0
8
All
COURT RESOLUTION & THE JV220 PROCESS
Percentage of California Foster Children
Authorized Psych Drugs
% Authorized Psych Drugs
18.50%
13.10%
12.60%
Los Angeles
State
9.10%
San Francisco
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Contra Costa
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State Initiatives
September 2010:
August 2012:
October 2012:
January 2012:
AB 12 Passed
Because Minds Matter Conference
Quality Improvement Project Charter Kick-off
“Monthly” Workgroup Calls
Clinical Workgroup
Data and Technology Workgroup
Youth, Family and Education Workgroup
August 2013:
September 2013-February 2014:
February 26th, 2014:
March 26th, 2014:
10/21/13
Draft Action Plan Circulated
State Process Suspended
Invitation Only Meeting
Meeting to Kick-off Workgroups
Anna Johnson
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Psychotropic Drug Concerns
Too Many
Too Much
Too Soon
Too Long
No Monitoring
(Mis- Over- Inaccurate) Diagnoses
No Risk/Benefit Profiles
Untested
Off-label
No Alternatives
Adverse Effects
Powerful Opposition
Untrained Caregivers
Lack of educational resources
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Psychotropic Drug Concerns
ABC News Investigation
Too Many
• Children in care
medicated
• Children on
multiple
medications
• Inaccurate
diagnoses
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Psychotropic Drug Concerns
Gabriel Myers Story
Too Much
• Above maximum
dosages
• Adult dosages for
children
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Psychotropic Drug Concerns
Too Soon
• Very young ages
• Too early in placement
• Before other
interventions
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Tiffany's Story
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Psychotropic Drug Concerns
Tristen's Story
Too Long
• No set monitoring
• No timeline to taper
off
• Authorization for
indefinite amount of
time
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Standard of Care
Policy Sources: Appropriate Use of Psychotropics
American Academy of Child & Adolescent
Psychiatry (AACAP)
Child Welfare League of America (CWLA)
HEDIS
American Academy of Pediatrics (AAP)
State Legislation
Medicaid Medical Directors Learning Network
(MMDLN)
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Prioritizing Policies & Actions
Special Populations
 Very young children
 Child-bearing age youth
 Youth transitioning from
care
 Group home youth
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Prioritizing Policies & Actions
Antipsychotics
 Limited FDA approval
 Off-label prescription
 Adverse Effects
 Disruptive Behavior
Diagnoses
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Prioritizing Policies & Actions
Maximum Dosing
 LA Parameters
 Connecticut Guidelines
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Prioritizing Policies & Actions
Polypharmacy
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Prioritizing Policies & Actions
Gaps in Medications
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Improving Prescribing Practices
Consultation & Second
Review
 California
 Child Psychiatrists
 Public Health Nurses
 Pharmacists
 Minnesota
 Washington
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Improving Prescribing Practices
Prior Authorizations/TARS
 CA 2006 TAR for
antipsychotic
prescriptions for
children under six
 Prescriptions fell from
5686 to 4200
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Improving Prescribing Practices
Monitoring Requirements
& Baseline Metabolic
Testing
 AK requires baseline lab
testing and 9 month
follow ups
 NJ has a detailed
monitoring protocol by
drug class
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Improving Prescribing Practices
Outlying Prescriber
Identification
 Many states use
Medicaid
pharmaceutical data to
identify inappropriate
prescribing patterns
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Improving Prescribing Practices
Academic Detailing
 Prescriber education
and outreach
 Safe Rx Amendment Act
of 2008 established an
academic detailing
program in Washington,
D.C.
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Discussion and Questions
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