Transcript File - Education Reach for Texans

Psychotropic Medication for
Children in Texas Conservatorship
Annual Education Reach for Texans
May 30, 2014
REGION 03 CHILD PROTECTIVE SERVICES
Sandra Galindo, BSN, RN
Regional Nurse Consultant
[email protected]
214/583-4151 office number
Goal
Update and review of 2013
Psychotropic Medication
Utilization Parmetner for
Children in Foster Care.
May 2014
Foster Parent
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Objectives
• Become familiar with the DFPS Psychotropic
Medication Utilization Parameters
– Briefly discuss non-pharmacological therapies.
– Review “Criteria Indicating Need for Further
Review of a Child’s Clinical Status”
– Explore and practice using Psychotropic
Medication Tables.
• generic/brand names
- Schedules
• Initial dosages
- Black box warnings
• Maximum dosages - Warnings & precautions
• Implications for foster parents and all team
members.
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Disclaimers
The contents of this training is for informational
purposes only and does not substitute for professional
medical advice.
“Always discuss specific questions or concerns
with the child’s prescribing doctor.”
There may be additional requirements for residential
child care providers or child placing agencies, i.e.,:
• Their agency’s specific policies and procedures on psychotropic
medications.
• Who may consent to the use of psychotropic medications for
children who are not in DFPS conservatorship.
Some children experience emotional
or behavioral problems.
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Contributing Factors
to Positive Outcomes
• Not changing placement or caregivers
• Caregiver characteristics are important:
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.
–
–
–
–
• Remember, children may act out as they adjust to a
new home and learn new rules.
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Non-pharmacological
Interventions
These specific methods a caregiver can use to help a child
manage behavior:
• Before considering psychotropic medications,
consider psychosocial therapies, behavior strategies,
and other non-pharmacological (non-medication)
interventions
• If psychotropic medications are started, provide nonpharmacological interventions along with psychotropic
medications.
• Each child is different, so the strategies should be
specific to the child’s needs and discussed with the
child’s therapist or medical provider.
o Individual therapy (child only)
o Family therapy
o Group therapy
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What is a symptom?
• Something experienced or felt
• A sign of an existence of something,
especially something undesirable
• May indicate a disease or other
disorder
• May change how a person feels
• May affect daily activities, like school,
jobs, relationships
• May cause dangerous actions
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BEHAVIORS
D
I
A
G
N
O
S
I
S
Anger/
Aggression
Impulsive
ADD/ADHD
/
/
Conduct
Disorder
/
Oppositional
Defiant
Disorder
/
/
Anxiety
Disorder
/
/
Adjustment
Disorder
/
/
Depressive
Disorder
/
Bi-polar
Disorder
/
Obsessive
Compulsive
Disorder
Withdrawn
Sad
Manipulative
/
/
/
/
/
/
/
/
Difficulty
with Focus
/
/
/
Anxious
/
/
/
/
/
/
/
/
/
/
/
PTSD
/
Teenagers
/
/
/
Foster Care
/
/
/
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Destructive
Defiant
/
/
/
/
/
/
/
/
/
/
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Seeking Medical Help
When:
• if a child has serious symptoms or
• is not getting better with other interventions,
• is a danger to himself/herself or others
Who:
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, see a psychiatrist.
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Purpose of
Psychotropic Meds
To treat emotional and
behavioral health symptoms and
disorders.
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Psychotropic Medication Utilization Parameters
for Foster Children
• Developed by:
• Texas Department of Family and Protective Services
• The University of Texas at Austin College of
Pharmacy with review and input provided by:
» Federation of Texas Psychiatry
» Texas Pediatric Society
» Texas Academy of Family Physicians
» Texas Medical Association
• December 2010
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Psychotropic Medication Utilization
Parameters for Foster Children
• Give general principles for doctors who prescribe
psychotropic medications to children in DFPS
conservatorship.
• 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.
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“Off label” prescriptions:
Doctors decision to prescribe “off label”
medications are 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.
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Considerations
1. Child psychiatry is continually evolving, so changes will
occur.
2. Lack of FDA approval is NOT synonymous with
inappropriate for children.
3.The list does not include all possible medications.
4. If a medication is not listed, it may still be
appropriate.
5. Many of these medications can be used for nonpsychiatric indications.
6. It can be appropriate to exceed the usual MAX dose.
7. Know the difference between a side effect and
adverse reactions.
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Non- approved Medications
by the Federal Drug Administration?
• Remember FDA regulates medications,
not doctors.
• Most medications regulated by FDA are
based on research in adults.
• Research & clinical experience lead to
“off label” prescribing.
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Medications are only one piece of
the puzzle…..
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http://www.dfps.state.tx.us/documents/C
hild_Protection/pdf/TxFosterCareParame
ters-September2013.pdf
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Criteria Indicating Need
for Further Review of a Child’s Clinical Status
•Absence of a thorough assessment or
•DSM IV diagnosis
• Four or more psychotropic medications
prescribed concomitantly (at the same time)
• Prescribing:
−
−
−
−
−
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2 or more concomitant antidepressants
2 or more concomitant alpha agonists
2 or more concomitant anti-psychotics
2 or more concomitant stimulants
3 or more concomitant mood stabilizers
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Criteria Indicating Need
for Further Review of a Child’s Clinical Status
• Prescribed psychotropic medication is
NOT consistent with the patient’s
diagnosis or target symptoms
• Poly-pharmacy is given before monotherapy
• Psychotropic med dose exceeds usual
recommended doses.
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Criteria “Continued”
• Psychotropic medications prescribed for children at a
very young age, i.e.,:
−
−
−
−
−
Stimulants-less than 3 years of age
Alpha Agonists less than four (4) years of age
Anti-depressants - less than 4 years of age
Anti-psychotics - less than 4 years of age
Mood stabilizers – less than 4 years of age
• Prescribing by a primary care provider for a diagnosis
for other than the following:
- ADHD
- Uncomplicated anxiety disorders
- Uncomplicated depression
• Appropriate monitoring of glucose and lipids at least
every 6 months for continuous prescribed antipsychotics
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Psychotropic Medication Tables
•
•
•
•
•
•
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generic/brand names
Initial dosages
Maximum dosages
Schedules
Black box warnings
Warnings & precautions
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Side Effects vs. Adverse Reactions
Side Effects
•
•
•
•
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Adverse Reactions
Common
Expected
Go away
Intervention usually
not required
Foster Parent
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•
•
•
•
Unwanted
Uncommon
Unexpected
Life threatening
Requires immediate
action
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Some behaviors are normal.
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Foster Parent Implications
Before the visit to the psychiatrist, find out as
much of this information as possible from the:
• Caseworker
• Previous caregiver, including birth parent
• Ask for and if needed, request copies of medical
records
• Ask for and if needed, request previous
psychological evaluations
• Previous medications
• Any adverse reactions to medications
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Foster Parent Implications:
• Share with the doctor (and the worker) any changes,
good or bad, i.e.,
• The addition of another child to the foster home,
i.e., birth or placement another child
• Any changes in sleep
• Any changes in grades
• Changes in diet or weight loss or gain
• Stress
• Changes in Mood
• Any changes related to alcohol or other
substance experimentation.
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Foster Parent Implications:
• Avoid rescheduling appointments.
• As the medical consenter and/or foster
parent, practice “Assent”
− Discuss Psychotropic Medications with children,
especially teens.
− 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.
− Ask the child if he has any questions or concerns.
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More Implications
• Share with CPS and CASA the child’s medications and
the psychiatric plan of treatment:
– Know the diagnosis or target symptom the
medication prescribed for
– Know the generic/brand name, dosage, route &
frequency given
– Note and document the child’s progress on the
medication
– Know adverse reactions or side effects to the
medications.
– Are there special instructions for giving any
medications, i.e., with food or at a certain time of
day.
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Foster Parent Implications
• Know your role and responsibilities as
the medical consenter.
• Be familiar with the court report done
by the caseworker.
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Foster Parent Resources
• For help, contact a Behavioral
Health service manager with
STAR Health.
• Become familiar with the Health
Passport at
http://www.fostercaretx.com/
• Call the regional nurse consultant
for help and/or other subject
matter experts.
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Foster Parent Resources
• Take a class on behavior intervention or
trauma-informed care.
• Work 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.
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