Melissa D. Carter, JD Barton Child Law & Policy Center Brent Wilson, MD Child Welfare Collaborative

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1 Melissa D. Carter, JD Barton Child Law & Policy Center Brent Wilson, MD Child Welfare Collaborative

2 Scope of the Problem Legal and Policy Considerations Social Work and Medical Practices Advocacy Opportunities and Additional Resources

3 Higher risk for EBDs Psychotropic medications used more often Tufts study (September 2010) General population: 4% Foster care population: 13 52% Increased rate of polypharmacy Rutgers / MMDLN (June 2010) 9x the rate of antipsychotic usage when compared to general Medicaid population

13 52% Increased rate of polypharmacy Rutgers / MMDLN (June 2010) 9x

4 Antidepressants SSRIs (Prozac, Zoloft, Celexa) SNRIs (Effexor, Cymbalta, Pristiq) TCAs/MAOIs Other Antidepressants (Wellbutrin, Trazodone) Mood Stabilizers Also termed anticonvulsants/anti epileptic drugs (AEDs)

5 Antipsychotics Atypical (Zyprexa, Seroquel, Risperdal) Typical (Haldol, Thorazine, Prolixin) Benzodiazepines (Ativan, Klonopin, Xanax) ADHD Medications Stimulants (Adderall, Ritalin, Concerta) Other ADHD medications (Tenex, Clonidine)

(Ativan, Klonopin, Xanax) ADHD Medications Stimulants

6 Concern exists for multiple l reasons: Over diagnosis Too many medications Misdiagnosis Inappropriate medications Under recognition Treatment withheld when necessary Diagnosis without appropriate treatment Treatment without appropriate monitoring Medication side effects Cost to state Medicaid systems

when necessary Diagnosis without appropriate treatment Treatment without

7 Unique # of Children in Foster Care w/in FY2010: 33, 330 #of Different Medications # of Children w/ Prescription for Psychotropic/Antipsychotic % of Total Medication 1+ Psychotropic 7, % 2+ 4, % 4+ 1, % % 1+ Antipsychotic 3, % 2+ 1, % % %

of Total Medication 1+ Psychotropic 7,542 32.5% 2+ 4,007 17.3% 4+ 1,032 4.

8 Race Black: 3,596 unique patients / 35,994 Rxs Caucasian: 3,746 unique patients / 46,018 Rx s Gender Female: 3,144 unique patients / 33,974 Rx s Male: 4,398 unique patients/ 50,011 Rx s Region Atlanta, Central, North, Southeast, Southwest, East Age Group 0 4: 399 unique patients / 1,466 Rx s 5 12: 3,965 unique patients / 42, Rx s 13 17: 3,344 unique patients / 36,493 Rx s 18 21: 447 unique patients / 3,538 Rx s For all age groups, psychotropic antihyperkinesis was the most commonly prescribed drug group

Group 0 4: 399 unique patients / 1,466 Rx s 5 12: 3,965 unique patients / 42,488 488 Rx s 13 17: 3,344 unique patients / 36,493

9 Who makes informed treatment decisions on behalf of children in foster care? Are non pharmacological treatments being considered d as alternatives ti or additions to a medication regimen? How are these medicines, most of which do not have FDA approval lfor use in children, affecting the future health of youth? Are children receiving appropriate assessments as well as proper follow up and monitoring? i What is the impact on permanency for children who are functioning at sub optimal levels? Others???

How are these medicines, most of which do not have FDA approval lfor use in children, affecting the future health of youth?

10 Consent to surgical or medical treatment (O.C.G.A ) Any parent, whether adult or minor, for a minor child; Any person temporarily standing in loco parentis, and any guardian; Any female, regardless of age, when given in connection with pregnancy or childbirth Minors may not refuse treatment No mature minor exception (Novak v. Cobb Kennestone Hospital) Minors may consent to drug abuse treatment (O.C.G.A ) Authority of juvenile court to order medical examination or treatment (O.C.G.A (b)): 11 12(b)) Physical or psychological exam, Medical or surgical treatment of a child For a serious physical condition or illness which, in the opinion of a licensed physician, requires prompt treatment Without parental consent.

connection with pregnancy or childbirth Minors may not refuse treatment No mature minor exception (Novak v. Cobb Kennestone Hospital) Minors may consent to drug abuse treatment (O.C.G.A.

11 Consent tissues Risk/benefit discussion Knowing, voluntary, intelligent Knowledge of all alternative treatments Right to refuse treatment Who can legally consent? Either/both parent(s), if in parental custody Judge Agency consents to ordinary medical care Does psychotropic drug therapy constitute extraordinary medical treatment? Limitations on state as parent An informed consent conversation

Either/both parent(s), if in parental custody Judge Agency consents to ordinary medical care Does

12 Competent minors? Parents don t always act in the best interest of their child(ren) The science of youthful decision making Competency as a function of age Determining capacity to consent Factual understanding di of the problem and treatment t t alternatives; ti Rational decision making processes; Appreciation of personal implications of decision; Ability to make and communicate a reasonable choice Research conclusions Improved treatment effectiveness Positive perception of procedural justice Assent v. consent

function of age Determining capacity to consent Factual understanding di of the problem and treatment t t alternatives; ti

13 Foster Care Social Services Manual 1011 (Needs of the Child) CCFA referral by day 4 in care (1011.1) FTM w/in 9 days of child s placement, other opportunity to meet with parent (1011.2) discuss: Any medications the child is taking (name, dose, when to administer, reason) Any physical, mental health, or developmental problems the parent has observed or has concerns about Obtain child s family health info and record, release of information to obtain all child s health records Communicate with foster parent or other placement provider about child s health care needs; provide foster parent with copy of emergency intake form, encourage parent to discuss medical needs with foster parent

2) discuss: Any medications the child is taking (name, dose, when to administer, reason) Any physical, mental health, or developmental problems the parent has observed or

14 Inform parent of any injuries, i accidents or major illnesses of the child while in care; make effort to contact parent prior to surgery for parental permission Silent as to drug therapy When the child is in foster care, the county department acts as a legal custodian and exercises such rights as dt determining ii the nature of care and treatment of the child, including routine medical and dental care.

is in foster care, the county department acts as a legal custodian and exercises such rights as dt

15 Children who do not receive a CCFA shall have a psychological or psychiatric evaluation completed with a written report w/in 30 calendar days of the date of removal, except: Children < age 4 Children who have had an evaluation w/in the past 6 months Obtain and document diagnosis and treatment info in the case record Discuss treatment recommendations and plans for implementation with the parent, foster parent, relative caregiver, other provider

evaluation w/in the past 6 months Obtain and document diagnosis and treatment info in the case record Discuss

16 Medication information Package insert (FDA indication, side effects) Dosing schedule (dose, frequency) Ask for medication administration record (MAR) Consent process Medication combinations that prompt consultation Medications used to treat side effects rather than underlying disorder

record (MAR) Consent process Medication combinations that prompt

17 Individual id child advocacy Psychotropic Medication Oversight Pilot Project Background: Cold Case Project, House Bill 23 Deliverables: Development of medical utilization parameters Limited case review and consultation Training in select target sites Final report with recommendations Partners: Casey Family Programs, Barton Center, Child Wlf Welfare Cllb Collaborative, and dyou! To subscribe to project listserv,

in select target sites Final report with recommendations Partners: Casey Family Programs, Barton Center, Child Wlf

18 American Academy of Child and Adolescent Psychiatry (AACAP): Search Package Inserts: NIMH Medication Guide: h ih /h ti / ental health medications/index.shtml Fostering Connections Act: National Child Traumatic Stress Network:

nimh.nih.gov/health/publications/m h ih /h ti / ental health medications/index.

Overview of Mental Health Medication Trends

Overview of Mental Health Medication Trends America s State of Mind Report is a Medco Health Solutions, Inc. analysis examining trends in the utilization of mental health related medications among the insured population. The research reviewed prescription