Psychotropic Medication in Foster Care...in foster care is to be provided to group home administrators, foster parents, child welfare social workers, probation officers, public health

Version1.0|2017

PsychotropicMedicationinFosterCare

TraineeGuide

TraineeGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 2

TableofContents:Background and Context ................................................................................................. 3Curriculum Introduction ................................................................................................... 6Agenda ............................................................................................................................ 7Learning Objectives ......................................................................................................... 8Segment 1: Welcome and Introductions ......................................................................... 9Segment 2: Laws and Regulations ................................................................................ 10Segment 3: Court Process and Forms .......................................................................... 13Segment 4: Trauma ....................................................................................................... 15Segment 5: Accessing Services .................................................................................... 20Segment 6: Psychotropic Medication ............................................................................ 27Segment 7: Using the California Guidelines .................................................................. 38Segment 8: Wrap Up and Evaluation ............................................................................ 43Resources ..................................................................................................................... 44References .................................................................................................................... 45


BackgroundandContextTheuseofpsychotropicmedicationamongchildrenandyouthintheUnitedStateshasincreasedsignificantlyoverthelasttwodecades,particularlyforchildrenandyouthinfostercare(Longhofer,Floersch,&Okpych,2011;Raghavan,Lama,Kohl,&Hamilton,2010).Raghavanandcolleagues(2005)estimatethat13%ofallchildrenandyouthinthechildwelfaresystemnationwidereceivepsychotropicmedicationscomparedto4%ofchildrenandyouthinthegeneralpopulation.In2014theSanJoseMercuryNewsfoundthatfrom2004to2014,nearly1outof4adolescentsintheCaliforniafostercaresystemreceivedpsychotropicmedications—3.5timestherateforalladolescentsnationwide.Ofchildrenandyouthincarewhowereprescribedpsychotropicmedications,60%receivedthestrongestclass—antipsychotics.Whatisparticularlyconcerningistheprescriptionofmultiplemedications(i.e.,polypharmacy).Thenewspaperstudyalsofoundthatin2013,12.2%ofchildrenandyouthincarewhowereprescribedmedicationswereprescribedmorethanonemedicationatatime.

Mackieandcolleagues(2011)listanumberoffactors,whichmayormaynotberelatedtoclinicalneed,thatexplainwhythispopulationofchildrenandyoutharedisproportionatelyprescribedpsychotropicmedications,including:higherratesoftraumavictimizationandmentalhealthdisordersfoundinthispopulation;traumacausedbybeingremovedfromfamilyoforiginandmultipleplacementchangesthereafter;andthecomplexemotionalandbehavioralsymptomsthataccompanyalltheseunderlyingcircumstances;lackofclearoversightandmonitoringguidelinesandprotocols;anincreaseinmedicationprescriptionsinoutpatientsettings;andinadequateaccesstoMedicaidservices.

Researchrepeatedlyfindsthatchildrenandyouthinthefostercaresystemarediagnosedwithmentalhealthdisordersmoreoftenthanchildrennotinfostercareandarethereforemorelikelytobeprescribedpsychotropicmedications(Longhofer,Floersch,&Okpych,2011;Sheldon,Berwick,&Hyde,2011).Themostcommondiagnosesamongchildrenandyouthinfostercareareconductdisorder/oppositionaldefiantdisorder,depression,attentiondeficit/hyperactivitydisorder,andposttraumaticstressdisorder.Commonlyprescribedmedicationsforchildrenandyouthinfostercareincludeantipsychoticstotreatschizophrenia,bipolardisorder,andautismwithirritability;stimulantsto


treatsymptomsofattentiondeficithyperactivitydisorder;antidepressantstotreatmajordepressionandobsessivecompulsivedisorder;andmoodstabilizersforaggressivebehaviorandunspecifiedemotionalproblems.

Inresponsetothisdata,Californiahastakenstepstobuilduponpreviouslegislationandexpandanddevelopnewguidelinesthatcontinuetopromotethebasicprinciplesofsafety,permanency,andwellbeing,withtheaddedgoalofreducingshort-andlong-termharmcausedbyinappropriateprescriptionsanduseofpsychotropicmedications.AspartoftheFosterCareQualityImprovementProject,TheCaliforniaDepartmentofHealthCareServices(DHCS)andtheCDSSreleasedtheCaliforniaGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCare,2015.Thenewguidelinescreateasharedunderstandingofoversightandmonitoringofpsychotropicmedicationpracticesforbothchildwelfareservicesandmentalhealthservices.Theguidelinessetexpectationsforphysicians,socialworkers,maturechildrenandyouth,parents,caregivers,Tribalmembers,andallotherpsychotropicmedicationstakeholderstocollaborateinstrengtheningtheoversightandmonitoringofpsychotropicmedications("Californiaguidelines,"2015).All-CountyInformationNoticeNo.1-05-14providesdetailsaboutsharingrequiredinformationwithcaregiverstofacilitatetheirinvolvementinprovidingcareforchildrenandyouth.

SenateBill238,signedintolawbyGovernorBrownonOctober6thof2015stipulatesthatcertainprofessionalsandotherswhoworkwithchildrenandyouthinfostercareshouldbeprovidedtrainingaboutimportanttopicsrelatedtotheadministrationofpsychotropicmedicationtothosechildrenandyouth.Specifically,trainingaboutpsychotropicmedicationandtraumaasrelatedtochildrenandyouthinfostercareistobeprovidedtogrouphomeadministrators,fosterparents,childwelfaresocialworkers,probationofficers,publichealthnurses,dependencycourtjudgesandattorneys,courtappointedcounselandspecialadvocatesalongwithinformationaboutbehavioralhealthandsubstanceuse.

Severalmediasourcesandotherstudieshaverecentlyrevealedthattherateofpsychotropicmedicationprescriptionsforchildrenandyouthinfostercareishigherthanthegeneralpopulation.Analarmingnumberofchildrenhavebeenprescribedmultiplepotentclassesofdrugstobetakensimultaneously.Thiscoverageandothermovementstoimprovementalhealthservicesinfostercareproducedseveralreformlaws.Theselawsmakeexplicitthatchildrenandyouthinfostercare,alongwiththeirfamiliesandrepresentatives,mustbeallowedtoprovideinputintowhetherornotpsychotropicmedicationispartoftheirtreatmentplan.

Ratherthanworkingfromtheassumptionthatsymptomsandbehaviorsarenecessarilyindicativeofmentalillness,thesereformsencouragetheuseofatrauma-informedlenstoviewthechild’senvironmentandexperiencesaspossiblesourcesofbehaviororsymptomsandtoexploreabroadrangeoftreatmentoptions.


Psychotropicmedicationsareonetoolamongmanythatmaybeusedtoaddressbehavioralhealthconcerns.Theymustbeconsideredverycarefullyasthelong-termeffectsofthesemedicationsondevelopingbrainsisunknownandpotentialsideeffectscanbesevere.

Atthetimeofthiswriting,theCaliforniaDepartmentofSocialServicesisengagedinthedevelopmentoftheCaliforniaChildWelfareCorePracticeModel,whichsubsumesthePathwaystoMentalHealthServicesCorePracticeModelwithinalargerpracticeframeworkthatintegratesthechildwelfaresystemwithotherchild-andfamily-servingsystemsinthepublicsectorandtheirpartners.Inturn,theCaliforniaChildWelfareCorePracticeModelispartofatripartite“SharedApproachtoCalifornia’sChildren,Youth,andFamilies”withthepublicsystemsofbehavioralhealthandjuvenilejustice,whicharealsoinprocessofdevelopingpracticemodelsfortheirrespectivefieldsofpractice.An“IntegratedStatewideTrainingPlan”iscurrentlyunderwaywhichwillreflectthepracticeandservicedeliveryenvironmentsofthechildwelfare,behavioralhealth,andjuvenilejusticesystemsunderthe“SharedApproach.”ThiscurriculumiscongruentwiththedevelopingCaliforniaChildWelfareCorePracticeModelandwiththeforthcoming“IntegratedStatewideTrainingPlan.”TheCorePracticeModel(CPM)setsthefoundationforacommonpracticeframeworkthatintegratesbehavioralhealthscreenings,referrals,serviceplanning,servicedelivery,andoverallcoordinationandcasemanagementamongallthoseinvolvedinworkingwithchildrenwhoreceiveservicesfromchildwelfareandbehavioralhealthsystemsinthepublicsector.Theeffectiveengagementoffamiliesinthereferralandtreatmentprocessfortheirchildrenisintegraltothismission.TheCPMdescribesstandardsandexpectationsforpracticebehaviorsbychildwelfareandbehavioralhealthstaffthatensuresandsupportsmeaningfulparticipationbyfamiliesinthecareandtreatmentoftheirchildren.ChildandfamilyteamingisaservicerequirementforchildrenwhoqualifyforIntensiveCareCoordination,andwillsoonbethestandardthroughoutchildwelfare.Forchildrenandyouthwithidentifiedmentalhealthissues,childandfamilyteamingisstronglyrecommended.Childrenandyouthforwhompsychotropicmedicationisbeingrequestedfromthecourtwilllikelyfallintooneofthesecategories.


CurriculumIntroduction

Duration:OneDay(9:00am-4:00pm,one-hourlunchbreak,two15-minutebreaks)

Thiscurriculumprovides:• Anoverviewoftheuses,benefits,andrisksofpsychotropicmedication.• Informationabouttraumaandhowitcaninformcareandtreatmentdecisions.• Guidanceforprofessionalstocreatetreatmentplansandteamwithfamiliesandotherprofessionalsto

makeandmonitortreatmentdecisions(e.g.,publichealthnurses,behavioralhealthproviders,schoolpersonnel,doctors,juvenileprobationofficers,CASAs,andotherindividualsinthefamilysupportnetworksuchascoaches,clergy,etc.).

• Howtolocateandusetheformsandinformationalmaterialsinthecourtapprovalprocess(JV-220).

ThecoreresourceforthistopicistheCaliforniaGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCare.Themostupdatedversionwillbeavailableat:http://www.dhcs.ca.gov/provgovpart/pharmacy/Documents/QIP_Guidelines.pdf

TheGuidelinesoutline• Basicprinciplesandvalues,• Expectationsregardingthedevelopmentandmonitoringoftreatmentplans(emotionalandbehavioral

healthcare,psychosocialservicesandnon-pharmacologicaltreatments),• Principlesforinformedconsenttomedication,and• Principlesgoverningmedicationsafety.

California’sPathwaystoMentalHealthpracticemodelisalsoahelpfulresource.Themostrecentversionofwhichmaybefoundhere:http://www.dhcs.ca.gov/Documents/KACorePracticeModelGuideFINAL3-1-13.pdf

AsistheCaliforniachildwelfarecorepracticemodel(CPM),themostrecentversionofwhichcanbefoundhere:http://calswec.berkeley.edu/california-child-welfare-core-practice-model-0

Theessentialdocument,theFosterCareYouth’sMentalHealthBillofRights,canbefoundhere:http://www.childsworld.ca.gov/res/pdf/QIP_PUB488.pdf

TheCaliforniaRulesofCourt5.640,whichgoverntheJV-220courtprocesscanbefoundat:http://www.courts.ca.gov/cms/rules/index.cfm?title=five&linkid=rule5_640

Acceptedpracticeandlocalrulesofcourtvaryacrosscounties,andthesematerialswillnotcoverallthesevariances.Knowingthespecificpracticesofthecountyforwhichyouareworkingisanimportantresponsibility,especiallywhenworkingwithchildrenandyouthwhohavementalorbehavioralhealthneeds.

Thiscurriculumisdevelopedwithpublicfundsandintendedforpublicuse.Useofcurriculumcontentshouldbecitedas:CaliforniaSocialWorkEducationCenter.(Ed.).(2016).PsychotropicMedicationinFosterCare.Berkeley,CA:CaliforniaSocialWorkEducationCenter.

Forquestionsregardingthecurriculum,contactShayK.O’Brien,[email protected],[email protected],orcallCalSWECat510-642-9272.


Agenda

Segment1 WelcomeandIntroductions

Segment2 LawsandRegulations

Segment3 CourtProcessandForms

BREAK

Segment4 Trauma

Segment5 AccessingServices

LUNCH

Segment6 PsychotropicMedication

BREAK

Segment7 UsingtheCaliforniaGuidelines

Segment8 Wrap-UpandEvaluations


LearningObjectives

Knowledge

K1:TraineeswillbeabletonameatleastthreekeypointsinthelawsandregulationsthatgovernadministrationofpsychotropicmedicationstochildrenandyouthinfostercareinCalifornia.

K2:Traineeswillbeabletonameatleastoneofthebasicprinciplesoftrauma-informedcareastheyrelatetouseofpsychotropicmedicationinfostercare.

K3:Traineeswillbeabletonameatleasttwocommonbehavioralhealthdiagnosesandtherelatedtreatmentoptions(bothpsychosocialandmedical)forchildren,youth,andyoungadultsinfostercare.

K4:Traineeswillbeabletodescribewhatdotoifsideeffectsarenoticedorreportedbyachild,youth,oryoungadultinfostercarewhoistakingprescribedpsychotropicmedication.

K5:Traineeswillbeabletolocateandutilizethecorrectstaterequiredforms(JV-217throughJV-224)whenamedicalproviderisstartingorcontinuingapsychotropicmedicationforachildoryouthinfostercare.

K6:Traineeswillbeabletodescribethenotificationprocessesusedinrequestingandmonitoringadministrationofpsychotropicmedications.

Skills

S1:Usingsampleplans,traineeswillutilizetheCaliforniaGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCareandthetoolsinitsappendicestoevaluateandmodifytreatmentplansthatincludepsychotropicmedicationdecisions.

a. PrescribingStandardsbyAgeGroup,b. ParametersforUseofPsychotropicMedicationforChildrenandAdolescents,c. ChallengesinDiagnosisandPrescribingPsychotropicMedication,andd. Algorithm/DecisionTreeforPrescribingPsychotropicMedication.

S2:Usingavignette,traineeswillbeabletoidentify:

a. Therelevantpartiesanddocumentationtobeincludedinthecourtprocess,b. Thoseparties’rightsandobligations,andc. Thetimelineforcourtrequests,decisions,andnotifications.

Values

V1:Traineeswillvaluebuildingonchildandfamilyresilienceandstrengthsinbothformalandinformalservicesusedtoamelioratethenegativeeffectsof

a. abuseand/orneglect;b. emotional,cognitive,and/orbehavioraldysregulations;andc. potentialmentalillness.

V2:Traineeswillvalueensuringthatthevoicesofchildren,youth,andyoungadultsareincorporatedintotreatmentplansandmedicationdecisions.

V3:Traineeswillvalueworkingwithamulti-disciplinaryteamtounderstandandmanagetheuseofpsychotropicmedicationbychildren,youth,andyoungadultsinfostercare.


Segment1:WelcomeandIntroductions

Pleaseintroduceyourselfbyproviding

• Yourname• Yourcounty/department/agency/unit• TheroleyouplayinFosterCare

Activity:GroupAgreements

Someexamplesoftheseagreementsare:

• Respecteachother’sperspectivesandexperience.• Mindfullyparticipatebykeepingtheenvironmentcollegialandproductive.• Ifanissuearises,addresstheinstructorontheside,one-on-one,ratherthaninfrontofthewholegroup.• Avoidinterrupting,ridiculing,ortalkingovereachother.• Considerprivacyandconfidentialityconcernscarefullybeforeyoudiscussanycaseoruseacurrentor

formercaseasanexample.

Youmayusethisspacetomakenoteoftheagreementsyourgroupmakes.


Segment2:LawsandRegulations

DefinitionofPsychotropicMedication

IntheWelfareandInstitutionsCode,psychotropicmedicationsaredefinedas:“Thosemedicationsprescribedtoaffectthecentralnervoussystemtotreatpsychiatricdisordersorillnesses.Theymayinclude,butarenotlimitedto,anxiolyticagents,antidepressants,moodstabilizers,antipsychoticmedications,anti-Parkinsonagents,hypnotics,medicationsfordementia,andpsychostimulants.”

TheCaliforniaDepartmentofSocialServicesandtheDepartmentofHealthCareServiceshavechosenthisdefinitionintheirGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCaredocument,whichwewilluselaterintheday.

BigPicture

Concernsthathavebeenraisedbyresearchstudies,governmentreportsandmediacoverageinclude:over-medication,off-labelmedication,multipleprescriptions,insufficientmonitoring,andmedicatingveryyoungpatients.

Researchandmediasourcesrevealthattherateofpsychotropicmedicationprescriptionsinfostercareishigherthanthegeneralpopulation,childrenhavebeenprescribedmultiplepotentclassesofdrugstobetakensimultaneouslyandwithoutascheduletoevaluateeffectiveness(inotherwords,permanently).Thiscoverageandothermovementstoimprovementalhealthservicesinfostercareproducedseveralreformlaws.Input:Theselawsmakeexplicitthatchildrenandyouthinfostercare,alongwiththeirfamiliesandrepresentatives,mustbeallowedtoprovideinputintowhetherornotpsychotropicmedicationispartoftheirtreatmentplan.Trauma:Ratherthanworkingfromtheassumptionthatsymptomsandbehaviorsarenecessarilyindicativeofmentalillness,thesereformsencouragetheuseofatrauma-informedlenstoviewthechild’senvironmentandexperiencesaspossiblesourcesofbehaviororsymptomsandtoexploreabroadrangeoftreatmentoptions.Broadarrayofservices:Psychotropicmedicationsareonlyonetoolamongmanythatmaybeusedtoaddressbehavioralhealthconcerns.Theymustbeconsideredverycarefullyasthelong-termeffectsofthesemedicationsondevelopingbrainsisunknownandpotentialsideeffectscanbesevere.Goalistogetappropriate,quality,accessiblemental/behavioralhealthservicestochildrenandyouthincare.

SenateBill238

Courtauthorizationprocess• Onlyajuvenilecourtjudicialofficercanordertheadministrationofpsychotropicmedicationstoachildor

youthinfostercare(exceptrarecaseswe’llcoverlater)• Thatofficermayonlydosobaseduponarequestfromaphysician.• Thatphysicianwillprovidereasonsfortherequestandadescriptionofthechild’sdiagnosisand

symptoms.• Thecourtwillreceiveinformationaboutthechild’soverallmentalhealthassessmentandtreatmentplan,

andprocessforperiodicoversightandevaluationtobefacilitatedbythesocialworker,publichealthnurseorothercountystaff.

• Caregiverreceivesnoticewithintwodaysofcourt’sdecision


ChildandFamilyInput• Providesopportunityforthechildandhisorherfamilyandcaregiver,court-appointedspecialadvocate,

thechild’stribe,orotherstoprovideinputonthemedicationsbeingrequested.• Requiresthatthechild’scaregiverreceiveacopyofanyresultingcourtorder.

PublicHealthNurses• SB238clarifiesthepublichealthnursingprograminchildwelfarewiththepurposeofpromotingand

enhancingthephysical,mental,dental,anddevelopmentalwell-beingofchildreninthechildwelfaresystem.

• PHNswillcollectanddocumentmedicalrecords,assistwithreferrals,andparticipateinmedicalcareplanningandcoordination.

MonthlyStateData• RequirestheCaliforniaDepartmentofSocialServicesisrequiredtoissueamonthlyreporttoindicate

whenredflagsarepresent.Forexample,o whenmultiplemedicationsareprescribedforthesamechild,oro whenunusuallyhighdosesareindicated,oro whenprescriptionsareforchildrenwhoare5yearsoldoryounger.

• Countiesaresubsequentlyrequiredtosharerelevantinformationwithappropriatejuvenilecourt,attorneys,countydepartmentofbehavioralhealth,andCASAs.

Recommendsthistraining• SB238suggeststrainingabouttheauthorization,uses,risks,andbenefitsofpsychotropicmedicationas

wellastrainingonself-administration,oversight,andmonitoringofthosemedications.• Thelawsuggeststhatthetrainingincludeinformationabouttrauma,substanceusedisorder,andmental

healthtreatments.

SenateBill319

SenateBill319addressestheroleofFosterCarePublicHealthNurses.

Publichealthnurseswill:• monitoruseofpsychotropicmedicationbychildrenandyouthinfostercare,• documentinitialandfollow-uphealthscreenings,• collecthealthinformationtodetermineappropriatereferral,• helpchildrenandfamiliesconnectwiththeservicestheyneed,• assistwithtreatmentplanning,• assessprogresstowardtreatmentgoals,and• advocatetoensurethatthehealthneedsofthechildaremetandthatthechildandfamilycanmake

informeddecisionsabouttheirownmedicaltreatmentandhealthcaregoals.

Thespecificpracticesandprotocolsfortheseactivitieswillvaryaccordingtocountydecisions.

SenateBill484

ThislawappliesprimarilytoGroupHomes.Runawayandemergencysheltersareexemptedfromtherequirementsofthisbill.


Grouphomesarerequiredtousepsychotropicmedicationinaccordancewiththewrittendirectionsoftheprescribingphysicianasauthorizedbythejuvenilecourt.

GroupHomesaretomaintainspecificinformationinthechild’srecords• Acopyofthecourtorderthatauthorizestheadministrationofprescribedmedication• Aseparatelogforeachmedicationthechildistakingthatincludes:

ü thenameofthemedication,ü thedateofprescription,ü thequantityofmedicineandthenumberofrefills,ü dosageanddirections,andü thedateandtimewhenthechildtookeachdose.

Thislawalsodelineateshowthestatewillidentifygrouphomesthatwarrantadditionalreviewandmandatesvisitsatleastonceayeartoidentifiedfacilities.

SB484authorizesthedepartmentofsocialservicestoshareinformationaboutthesevisitswithcountyplacingagencies,socialworkersandprobationofficers,thecourt,anddependencycouncilortheMedicalBoardofCalifornia.

GrouphomeswhohavehadavisitorreportwillbeallowedtosubmitimprovementplanstoCDSSwithin30daysofthatvisit.

GrouphomeswillberequiredtoimplementalternativeprogramsandservicesthatadheretonewperformancestandardsandoutcomemeasurestobedesignedbyCDSSbyJanuary1,2017

LegislativeUpdates

SenateBills• 1174—prescriber-oversightbillallowingMedicalBoardofCaliforniatoexamineprescriptionpatterns• 1291—improvestransparencyandtrackingofmentalhealthservicesforchildrenandyouthinfostercare

InformationaboutnewCalifornialawsconcerninghealthcanbefoundhere:http://www.dhcs.ca.gov/formsandpubs/laws/Pages/LawsandRegulations.aspx

LinkstotheinvestigativejournalismdonebySanJoseMercury-Newscanbefoundhere:http://www.mercurynews.com/tag/drugging-our-kids/

SupplementalMaterials:

• StateAuditSummary• ACF,Children’sBureauInformationMemorandum12-03• FulltextofSB238• FulltextofSB319• FulltextofSB484• ACL16-48RoleofFosterCarePublicHealthNurses


Segment3:CourtProcessandForms

CourtProcess

MuchoftheworkdonebytheCFTorothertreatmentteamespeciallythehealthhistory,pasttreatmentsdocumentationandrisk/benefitanalysis,willbeusefulforthecourtifpsychotropicmedicationisselectedaspartofthetreatmentplan.ThenewcourtprocessusedtoconsiderarequestedpsychotropicmedicationbeadministeredtoachildoryouthincarebecameeffectiveonJuly1st,2016.Itstrengthensthecontinuity,quality,andcoordinationofcare.Continuityisimprovedbythesharingofmedicalandtreatmenthistoryacrossagencies,qualityofcareisenhancedbyimprovedmonitoringandclearexpectations,andcoordinationiseasierbecausesocialworkersandpublichealthnurseshaveeasieraccesstonecessaryinformation.

JudicialReview

Bylaw,achildwhoisawardordependentofjuvenilecourtorinfostercaremaynotreceivepsychotropicmedicationwithoutacourtorder.TheJudicialCouncilhascreatedaseriesofformsusedtorequestthisorderfromthecourt.Theymakeupthe“JV-220Process.”Thereareonlythreeexceptionstothismandate.Oneexceptionisifthechildoryouthlivesinanout-of-homefacilitythatisnotconsideredfostercare.Anotherexceptioniswhenthereisapreviouscourtorderthatgivesthechild’sparentstheauthoritytoapproveorrefusethemedication.Thefinalexceptionisinthecaseofanemergency.Adoctormayadministerpsychotropicmedicationtoachildiftheyposeaseriousrisktothemselvesorothers,topreventdeathorseriousharm,orifwaitingwouldcreatesignificantsuffering.Afteremergencyadministrationofmedication,thedoctorhasnomorethan2daystoseekcourtauthorizationthroughtheJV-220process.Judicialapprovalissoughtbythesocialworkerorprobationofficerwiththechild’sprescribingphysician.Theyworkincollaborationwiththechild,hisorhercourtandtribalrepresentatives,alongwithfamilymembersandcaregivers.PublicHealthNursesarekeymembersoftreatmentteamsforchildrenandyouthinfostercare.CivilCodesection56.103statesthatmedicalinformation,barringpsychotherapynotes,andotherrestrictedhealthinformationmaybesharedwithPublicHealthNursesorPHNs,buttheRulesofCourtthatdelineatetheJV-220processdonotincludePHNsexplicitly.CountieswillvaryintheapproachtheytaketoincorporatingtheroleofPHNsandthedatasharingactivities

Exceptions

Judicialapprovalisrequiredexceptinthesecircumstances.• Continuationofmedicinefrombeforetheywereinfostercare.• Parent/legalguardianremainstheonlypersonallowedtoconsenttotreatment.• Emergency—rareandshort-term• Non-MinorDependentshavetheirownconsenttograntordeny,Courthasnoauthority• Childoryouthislivinginout-of-homeplacementnotconsideredfostercare(e.g.juveniledetention

orvoluntaryplacement)


RequiredForms

Hereisaquickintroductiontotheformsusedinthecourtapprovalprocessforrequestingandadministeringapsychotropicmedicationtoachildinfostercare.Useofthemissometimescalledthe“JV-220Process.”• JV-220istheformthatinitiatestherequesttoadministerpsychotropicdrugstoachildoryouthincare.• JV-220(A)isanattachmenttotheJV-220andcontainsthephysician’sstatement.Itmustaccompanythe

JV-220,unlesstherequestistocontinueanongoingtreatmentwithoutchangesandisrequestedbythesamedoctor.Inthatcase,JV-220(B)shouldbeattached.TheseJV-220formsarecommonlyreferredtoastheApplication.

• JV-221istheformthatshowstheCourtthatallpartieswitharighttoreceivenoticewereservedacopyoftheApplicationandattachments.Wewillcoverthesepartiesmorethoroughlyinafewmoments.

• JV-223istheOrderontheApplicationandistheformtheCourtusestoeithergrantordenytheApplicationforPsychotropicMedication.

• JV-224isfiledwiththeCourtbythesocialworkerorprobationofficeratleast10calendardaysbeforeeachprogressreview.

• JV-217INFOisaGuidethatprovidesbriefdescriptionsofalltheformsrelatedtotheApplicationforPsychotropicMedication.ItissentalongwithnotificationsofapendingApplication.

OptionalForms

Inadditiontotherequiredforms,therearesomethatthefamilyandtreatmentteammaydecidetouse.Itisimportanttonotethatwhiletheseformsarelistedas“optional,”thatdoesnotmeanthatseekingtheinputoftheseindividualsisoptional.Itisjustthattheuseofthesespecificformsisnotrequired.Involvedpartiesmaycommunicatetheirthoughtsandfeelingsusingothermeans,buttheirinputshouldbesought.TheJV-218formcanbeusedbythechildforwhomthemedicationisrequested.ItisoneofavarietyofmethodsthechildmayusetoprovidetheirinputtotheCourt.JV-219isasimilarformthatmaybeusedbythecaregiver,CASA,orTribetoprovideastatementabouttheirfeelingsrelatedtotheApplicationforadministrationofapsychotropicmedicationtothechildinquestion.JV-222formisfiledwhentheparentorguardian,theattorneyofrecordforaparentorguardian,thechild,thechild’sattorneyorguardianadlitem,ortheIndianchild’sTribedoesnotagreethatthechildshouldtaketherecommendedmedication.

SupplementalMaterials:• JV-220FormsprovidedbyTrainer• JV-220HandoutsprovidedbyTrainer• CaliforniaRulesofCourt5.640• AmericanBarAssociation—PsychotropicMedicationandChildreninFosterCare:Tipsfor

AdvocatesandJudges


Segment4:Trauma

DefinitionofTrauma

SubstanceAbuseMentalHealthServicesAdministration’sdefinitionoftrauma:

“Individualtraumaresultsfromanevent,seriesofevents,orsetofcircumstancesthatisexperiencedbyanindividualasphysicallyoremotionallyharmfulorthreateningandthathaslastingadverseeffectsontheindividual’sfunctioningandphysical,social,emotional,orspiritualwell-being.”

Theinclusionof“setofcircumstances”incorporatestheexperienceofneglect,whichisthemostfrequentreasonthatchildrenandyouthareremovedfromtheirhomes.Therefore,thisdefinitionisimportantforworkwiththefostercarepopulation.Itdoesn’tcompletelyalignwiththediagnosticcriteriaforPTSD,sothisisanareathatrequiresattention.Thetrauma-informedapproachisofparticularimportancewhenwearediscussingmentalandbehavioralhealthinterventions.Often,thesignsandsymptomsoftraumacanresemblethoseofmentalillnessorbehaviordisorders.Thesesymptomsandbehaviorsmightthenbetreatedasamentalillnessorchemicalimbalanceand/orwithpsychotropicmedications,thuscausingmissedopportunitiestoaddressthetraumaaswellasincreasingthelikelihoodofaddingunduestressorevenre-traumatizingtheindividual.

ThethreeE’softrauma

Thisdefinitionhighlightsthethreecomponentsoftrauma,whicharetheeventorthecircumstance,theexperienceoftheevent,andtheeffectoftheexperience.THEEVENT:Thesourceofpotentialtraumaisaneventorcircumstancethatcausessignificantstress.Noteverychildexposedtostresswilldeveloptrauma.Examplesmayincludetheactualorextremethreatofphysicalorpsychologicalharmorsevere,life-threateningneglect.Theseeventsandcircumstancesmayhappenasasingleoccurrenceorrepeatedlyovertime.Traumacanalsooccurwhenanindividualwitnessesextremethreatsorstressfulcircumstancesexperiencedbysomeonetheycareabout.EXPERIENCE:Thesingularexperienceanindividualhasoftheseeventsorcircumstancesdetermineswhetheritisatraumaticevent.Aparticulareventmaybetraumaticforoneperson,butnotforanother.Feelingsofpowerlessness,humiliation,guilt,shame,betrayal,orsilencingoftenshapetheexperienceoftheevent.Howtheeventisexperiencedmaybelinkedtoarangeoffactorsincludingtheindividual’sculturalbeliefs,availabilityofsocialsupports,ordevelopmentalstageatthetimetheeventoreventsoccurred.EFFECTS:Acriticalcomponentofdeterminingifanexperiencewastraumaticforanindividualisthepresenceoflong-lastingandadverseeffects.Theymayoccurimmediately,ornot.Sometimesadverseeffectsarenotnoticeduntilmuchlater,butarenonethelesscausedbythepreviousEventsandExperiences.

TraumaandFosterCare

Childrenandyouthcurrentlyorformerlyinfostercarehavelivedthroughatleastoneeventwhichcouldbetraumaticforthem:theywereremovedfromtheirhome.Theylostaccesstotheirfamilyforatleastsometime.Serviceswithinthefostercaresystem,whicharedesignedtoprotectchildrenfromharm,can—inandofthemselves—betraumatizing,despiteourbestefforts.Forexample,removalfromtheirhome,separationfromsiblings,pets,andfamiliarenvironment,chaoticplacement,etc.Thereisalsothesignificantloss,abuse,and/orneglectthatthechildexperiencedwhichresultedinremovalfromtheirhome.Anyoftheseeventscancausetrauma.Therefore,itmakessensetoviewthispopulationthroughthelensofpotentialtraumaanditseffects.


Symptomslikesleepproblems,toiletingproblems,anger,aggressivebehaviors,depression,ordifficultysustainingattentionareallidentifiedbytheAmericanAcademyofPediatrics(2015)aspossiblepresentationsfromchildrenwithahistoryofadverseandpotentiallytraumaticexperiences.

That’swhyitisimportanttocarefullyscreenforandevaluatetraumawhenassessingtheneedsofchildrenoryouthandtokeepinmindthatchildrenaredoingthebesttheycanwiththecircumstancesthey’vegot.

Problematicbehaviorsandsymptomswillnotalwaysshowupimmediatelyfollowingtraumaticevents.Itmaytakemanyyearsforsymptomsoftraumaticexperiencestobecomeapparent.Itisnotuncommonforadolescencetobeatimewhenchildhoodtraumaisrevealedinphysiologicaland/orbehavioralsymptoms.Individualresponsesvarywidely,soitisimportanttocarefullyandcompassionatelyassesssymptomsandbehaviorsthroughatrauma-informedlensevenifnothingobviouslytraumatichashappenedrecentlyinthechild’slife.

TraumaandResilience

Unaddressedtraumasignificantlyincreasestheriskofmentalhealthconcerns,substanceusedisordersandchronicphysicaldiseases.Thesepotentialoutcomescanbemitigatedbyresilience.Resilienceiscomprisedofthreeinteractiveinfluences:1. Individualdifferencesintemperamentandcognitiveabilities2. Qualityofsocialrelationships—doesthechildhavepeersandadultstheycantrustandwhocareabout

them?3. Qualityofthebroaderenvironment,suchasschoolandneighborhoodResiliencecanbenoticed,heightened,andcenteredbytheuseofastrengths-basedapproachtoworkwithchildrenandfamilies.Focusingontheassetsandtoolsthatindividualsalreadypossessratherthanperceiveddeficitscanempowerindividualsandminimizelabelsandstigmas.Identifyingandbuildingonthestrengthsoftheindividual,theirsupportnetwork,andtheirenvironmentincreasesresilienceandcanimprovetheprotectivefactorsindealingwithpastandpotentialfuturetraumaandhelptomitigatenegativeeffectsfromstress.

NegativeEffectsofTrauma

Examplesofnegativeeffectsincludelimitedordisruptedabilityto:• copewiththenormalstressesandstrainsofdailyliving,• formrelationshipsormaynotbeabletotrustinorbenefitfromthem,• managecognitiveprocesses(suchasmemory,attention,thinking),• regulatebehavior,or• controltheexpressionofemotions.

Thesebehaviorsmaybeadaptiveandprotectivewhenthechildisinthestressfulenvironment,butcanbemisunderstoodaspathologicwhentheyareremovedfromthatenvironment.Noteverydysregulationisindicativeofadisease.


Thesenegativeeffectscansometimestaketheformofanger,violence,self-harm,distrustfulness,hypervigilance,numbness,substanceuse,nightmares,avoidance,and/orhopelessnessandtheycanwearapersondownphysically,mentally,andemotionally.Neurobiologyandongoinghealthandwell-beingmaybepermanentlyaltered.Survivorsoftraumahavealsohighlightedtheimpactoftheseeffectsonspiritualbeliefsandthecapacitytomakemeaningoftheseexperiences.Youmayhavenoticedthatallthesesymptomsresemblesymptomscommonlyassociatedwithmentalorbehavioralhealthdiagnoses.Traumaandmentalhealthoftenoverlap.Traumacanhavenegativeeffectsonachild’spsychologyand,conversely,mentalhealthissuescanincreasevulnerabilitytotrauma.Traumashouldbeconsideredatallpointsinmentalhealthandsubstanceuseservicesincludingprevention,treatment,andrecovery.

TraumaandSubstanceUse

Interrelatedandrisksgobothdirections.• Substanceuseasanattempttomanagetraumasymptoms(self-medicatingtheory).• Traumaoccursasresultofsubstanceuseandmaybemorelikely(youngpeopleusingsubstancesare

morelikelytoengageinriskybehaviorsandbenearpotentiallyabusiveordangerouspeople,mayberequiredtodoillegalthingstosupportaddiction,etc.).

• Similarpatternsanddysregulationinaddictionandtraumaticstress.Prioritizeintegratedandspecializedservices• Thesecanbechallengingtolocate,butarearequiredcomponentofMediCalviaEPSDT(seeMHSUDS

InformationNotice16-063intheSupplementalMaterials).• Integrationandresource-sharingcanoccurontreatmentteam.• Acknowledgingtraumaanditsrelationshipwithsubstanceusecanbeanempoweringaspectoftreatment

andrecovery.Youthmayengageinriskybehaviorsasaresultofuseandexperienceatraumaticeventand/ormaybelessabletocopewithatraumaticeventduetosubstanceusethantheirnon-usingpeers.Someserviceswon’tacceptfolkswhoareusingdrugsoralcoholintotheirmentalhealth/traumaservices,andPTSDissometimesanexclusioncriterionforsubstanceusetreatment.Treatmentteamswithprofessionalsfrombothareascanhelpmakesuretheservicesarecomplimentary.

Trauma-InformedToolsandServices

Thetrauma-informedapproachisofparticularimportancewhenwearediscussingmentalandbehavioralhealthinterventions.Often,thesignsandsymptomsoftraumacanresemblethoseofmentalillnessorbehaviordisorders.Thesesymptomsandbehaviorsmightthenbetreatedasamentalillnessand/orwithpsychotropicmedications,thuscausingmissedopportunitiestoaddressthetraumaaswellasincreasingthelikelihoodofaddingunduestressorevenre-traumatizingtheindividual.Whenassessingchildrenandyouthforservices,atrauma-informedapproachisimportantbecause:• Symptomscanbecopingmechanismsoradaptiveresponses.• Carefulassessmentiscrucialtoeffectivetreatment.• Thelongertraumaticstressgoesuntreated,thegreatertheriskofdevelopingmaladaptiveandpotential

dangerouscopingmechanisms.• Symptomsusedtofinddiagnosesoftenoverlapwithsymptoms/behaviorsresultingfromtrauma.


SymptomsthatOverlap:ChildTraumaandMentalIllness

Attentiondeficit/hyperactivitydisorder(ADHD)Restless,hyperactive,disorganized,and/oragitatedactivity;difficultysleeping,poorconcentration,andhypervigilantmotoractivity

Oppositionaldefiantdisorder(ODD) Apredominanceofangryoutburstsandirritability

Anxietydisorder(incl.socialanxiety),obsessive-compulsivedisorder(OCD),generalizedanxietydisorder(GAD),orphobia

Avoidanceoffearedstimuli,physiologicandpsychologicalhyperarousaluponexposuretofearedstimuli,sleepproblems,hypervigilance,andincreasedstartlereaction

Majordepressivedisorder(MDD)Self-injuriousbehaviorsasavoidantcopingwithtraumareminders,socialwithdrawal,affectivenumbing,and/orsleepingdifficulties

BipolarDisorder

Hyperarousalandotheranxietysymptomsmimickinghypomania;traumaticreenactmentmimickingaggressiveorhypersexualbehavior;andmaladaptiveattemptsatcognitivecopingmimickingpseudo-manicstatements

PanicDisorderStrikinganxietyandpsychologicalandphysiologicdistressuponexposuretotraumaremindersandavoidanceoftalkingaboutthetrauma

SubstanceAbuseDisorderDrugsand/oralcoholusedtonumboravoidtraumareminders

PsychoticDisorder

Severelyagitated,hypervigilance,flashbacks,sleepdisturbance,numbing,and/orsocialwithdrawal,unusualperceptions,impairmentofsensoriumandfluctuatinglevelsofconsciousness.

Note.AdaptedfromAddressingtheimpactoftraumabeforediagnosingmentalillnessinchildwelfares.International,byGriffin,etal.(2011),ChildWelfare,90(6),69–89.


Activity:SmallGroupDiscussion

1. Whataresomeexamplesofachild’sresilienceinthefaceoftrauma?Oratimewhenastrengths-basedapproachwasusedsuccessfullytoaddresstrauma?

2. Doyouordoesanyoneinyourgroupuseformaltraumaassessmentsorothertrauma-specifictools?Whatabouttrauma-informedserviceproviders?

Ifso,howaretheyused?Whatarethesuccessesandchallengesofhavingthisinformationandapproach?

Ifnot,doyouthinkitwouldbeusefultohavethesetools?Howwouldyouusethem?Howcanyougettheminyourcounty/agency?


• SAMHSA’sConceptofTraumaandGuidanceforaTrauma-InformedApproach• AmericanAcademyofPediatricsHelpingFosterandAdoptiveFamiliesCopewithTrauma• NationalRegistryofEvidence-BasedProgramsandPracticesBehindtheTerm:Trauma• NationalChildTraumaticStressNetwork’sTraumaandSubstanceAbuse• NationalChildTraumaticStressNetwork’sTipsforFindingHelp• ChadwickTrauma-InformedSystemsProject:EssentialElements


Segment5:AccessingServices

Person-CenteredApproach

Becausetraumaandstrengthsaresouniquetoeachindividual,assessmentandtreatmentplanningrequiretheuseofaPerson-CenteredApproach.Thisapproachcanbedefinedas:

“ahighlyindividualizedcomprehensiveapproachtoassessmentandservicesthatisfoundedonanunderstandingoftheperson’shistory,strengths,needs,andvisionofhisorherownrecoveryandincludesattentiontoissuesofculture,spirituality,trauma,andotherfactors.”

Forchildrenandyouthinfostercare,someotherfactorstoobservearegriefandloss,sexualorientation,genderidentityandexpression,andanythingelsethatthechildoryouthtellsyouisimportant.Thisapproachsharestheplanning,development,andmonitoringofserviceswiththepersonforwhomtheservicesareintended.

AccessingServices

AllchildrenandyouthinfostercareareeligibleforEarlyandPeriodicScreening,Diagnosis,andTreatment(EPSDT).TheEPSDTProgramisacomprehensivebenefitpackagewithinMedicaidspecificallyforchildrenuptoage21.Itincludes:

• medical,• dental,• substanceusedisordertreatment,and• mental/behavioralhealthcareservices.

AllchildreninvolvedwiththefostercaresystemareeligibleforfederalMedicaidbenefits,whichiscalledMedi-CalinCalifornia.TheEPSDTProgramemphasizespreventionandearlyintervention,andrequiresthatchildrenreceivecomprehensiveexaminationstoidentifyandaddresstreatmentneeds.ChildrenandyouthwhomeetmedicalnecessitycriteriaareeligibletoreceiveSpecialtyMentalHealthServices(SMHS).AccordingtotheMentalHealthandSubstanceUseDisorderServices(MHSUDS)InformationNotice16-061,inordertoreceiveSMHS,childrenandyouthmusthaveacovereddiagnosis—listedbelow—andmeetthefollowingcriteria:

1. Haveaconditionthatwouldnotberesponsivetophysicalhealthcarebasedtreatment;and

2. TheservicesarenecessarytocorrectorameliorateamentalillnessandconditiondiscoveredbyascreeningconductedbytheManagedCarePlan,theChildHealthandDisabilityPreventionProgram,oranyqualifiedprovideroperatingwithinthescopeofhisorherpractice,asdefinedbystatelawregardlessofwhetherornotthatproviderisaMedi-Calprovider.

Covereddiagnosesare:• PervasiveDevelopmentalDisorders,exceptAutisticDisorders• DisruptiveBehaviorandAttentionDeficitDisorders• FeedingandEatingDisordersofInfancyandEarlyChildhood• EliminationDisorders• OtherDisordersofInfancy,Childhood,orAdolescence


• SchizophreniaandotherPsychoticDisorders,exceptthoseduetoaGeneralMedicalCondition• MoodDisorders,exceptthoseduetoaGeneralMedicalCondition• AnxietyDisorders,exceptthoseduetoaGeneralMedicalCondition• SomatoformDisorders• FactitiousDisorders• DissociativeDisorders• Paraphilias• GenderIdentityDisorder• EatingDisorders• ImpulseControlDisordersNotElsewhereClassified• AdjustmentDisorders• PersonalityDisorders,excludingAntisocialPersonalityDisorder• Medication-InducedMovementDisordersrelatedtootherincludeddiagnoses.

Excludeddiagnoses(thoseforwhichtheMHPisnotresponsible):• MentalRetardation• LearningDisorders• MotorSkillsDisorder• CommunicationDisorders• AutisticDisorders(OtherPervasiveDevelopmentalDisordersareincluded)• TicDisorders• Delirium,Dementia,andAmnesticandOtherCognitiveDisorders• MentalDisordersDuetoaGeneralMedicalCondition• Substance-RelatedDisorders• SexualDysfunctions• SleepDisorders• AntisocialPersonalityDisorder

OthermentalhealthservicesavailablethroughMedi-Cal:

• TherapeuticBehavioralServices/Coach• IntensiveCareCoordination• IntensiveHome-BasedServices• TherapeuticFosterCare


InCalifornia,“non-specialty”mentalhealthservicesmaybeprovidedbyacounty’sManagedCarePlan.“Specialty”mentalhealthservices,mandatedEPSDT,areprovided(orarrangedtobeprovided)throughthecountyMentalHealthPlan.Belowarethetargetpopulationsandservicescoveredbyeach.

RightsofMedi-Calbeneficiaries

AllfamilieswithchildrenwhoareassessedforservicesunderEPSDTshouldreceiveaNoticeofActioninformingthemoftheresultsofthatassessment.TheNOAmaybedeliveredtothechildwelfareworker,andshouldbesharedwiththefamilyandthetreatmentteam.

Allcountymentalhealthplansmusthaveatoll-freenumber(listedbelow).

Beneficiarieshavearighttoreceive:• Ahandbookthatoutlineshowtofileagrievanceand/oranappealandwhatservicesareavailableto

them,and• Anelectronicversionofaproviderdirectorywithcontactinformation.

DeniedServices

Ifnecessaryservicesaredenied,terminated,reduced,ordelayedanappealmaybefiled.Contactyourcounty’sMHPortheHealthConsumerAllianceat888.804.3536orwww.healthconsumer.org.

TargetPopulationsandServices

Non-Specialty Mental Health Services Carved-in Effective 1/1/14

Mental Health Services� Individual and group mental health evaluation and treatment

(psychotherapy)�Psychological testing when clinically indicated to evaluate a

mental health condition�Outpatient services for monitoring drug therapy�Outpatient laboratory, medications, supplies, and

supplements�Psychiatric consultationAlcohol Abuse Services�Screening, Brief Intervention, and Referral to Treatment

Medi-Cal Managed Care Plans

(MCP)

County Mental Health Plan

(MHP)

Medi-Cal Specialty Mental Health Services

Outpatient Services�Mental Health Services (assessments, plan development,

therapy, rehabilitation and collateral, medication support)�Day Treatment services and rehabilitation�Crisis intervention and stabilization�Targeted Case Management�EPSDT specialty mental health services

Inpatient Services�Acute psychiatric inpatient hospital services�Psychiatric Health Facility services �Psychiatric Inpatient Hospital Professional Services if the

beneficiary is in a FFS hospital

Target Population: Children and adults eligible for outpatient non-specialty mental

health services ( mild to moderate conditions)

Target Population: Children and adults with disabling conditions that require mental health treatment (children; adults w/ severe cond.)

Medi-CalMentalHealthandSubstanceUseDisorderServices(MHSUDS)DeliverySystems

27


CorePracticeModelMental/BehavioralHealthScreeningFlow

ChildWelfareconductsBehavioralHealthScreening

IntakeandAnnually

EmergencyNeeds

Non-emergencyNeeds

NoCurrentBehavioralHealth

Needs

ChildWelfarereferstoCountyMental

HealthforWIC5150Evaluation

MonitorandEvaluateregularly

Screenagainatleast

annually

ChildandFamilyTeamdeterminesbestassessment.ANYqualifiedMediCalcliniciancanassess.

Then,countyMHPorManagedCarearrangefor/provideservices.

NOTE:Childrenandyouthwhoareassessedunder

EPSDTshouldreceiveaNoticeofActioninformingthemoftheresultoftheassessment.

Ifdeniedservices,thecaregivercanfile

anappeal.

Yes

BehavioralHealthnotifieslegalguardianandarrangesassessment

No

BehavioralHealthmeetswithChild

andFamilyTeamtostabilizeandsafety

plan


InformalServices

InformalMentalHealthServicesareactivitiesdeliberatelyintroducedtohelppromotehealingandalleviatesymptomsandtoprovidethechildoryouthopportunitiesfor:

• positivepeerinteraction,• self-discipline,• toleranceforfrustration,• enhancedself-esteem,• masteryofskills,• beingpartofsomethinglargerthantheirowncurrentcircumstance.

Theycanalsoprovideasupportiveadultwhomaybecomeamemberofthetreatmentteamorcanofferinsighttotheteam,likeacoachorinstructor.

Someinformalmentalhealthservicesthattheteammaychoosetoincludeinachild’streatmentplanarethefollowing:

• Exerciseorparticipationinorganizedorinformalsports,• Musicaltraininglikemusiclessons,choir,orband• Artorwritingclassesorindividualartisticexpression.• Participatingincommunitytheaterproductionsordramaactivitiesatschool• Interactingwithanimalscanbeverytherapeutic,ascanvolunteeringtohelpothers.• Meditation,changesindietandcookingorparticipatinginfoodpreparationandgardeningcanall

helpchildrenmanagestressandfeelconnected.

Involvementintheseactivitiesshouldnotbethreatenedorremovedaspartofdisciplinaryactionsastheyareimportanttothechild’sresilienceandwell-being.

Usecreativityandtheuniqueneedsanddesiresofeachindividualwhendevelopingthisportionofthetreatmentplan.Developingideasformanagingstressandenjoyingactivitiesispartoftreatment,sothechildoryouth’sengagementisvital.

FormalServices

Dependingupontheneedsofthechildandtheavailabilityofservicesinthecommunity,thetreatmentteammightconsiderthefollowing:MedicationSupportServices;oneofthemanytypesoftherapy,suchasindividual,family,orgrouptherapy;medicalcasemanagement,therapeuticbehavioralservices;wraparoundservices;intensivedaytreatment;orresidentialcare.Alldecisionsshouldprioritizetheneedsofthechildabovewhatismerelyconvenient.Aclearlinetothegoalsofthetreatmentplanshouldbeevidentinanyinterventionselected.TheAmericanAcademyofPediatricspartnerswithPracticeWisetocreateayearlylistofevidence-basedpsychosocialinterventions.Theyranktheinterventionsbasedonthequalityoftheresearchevidencethatsupportstheireffectiveness.Mentalhealthinterventionsmightbeincorporatedintoatreatmentplanwithorwithoutaccompanyingmedication.


CountyMentalHealthPlansContactList

CountyMentalHealthPlan PhoneNumber(s)

Alameda(andCityofBerkeley) (800)491-9099

Alpine (800)318-8212

Amador (888)310-6555

Butte (800)334-6622

Calaveras (800)499-3030

Colusa (888)793-6580

ContraCosta (888)678-7277

DelNorte (888)446-4408

ElDorado (800)929-1955

Fresno (800)654-3937

Glenn (800)507-3530

Humboldt (888)849-5728

Imperial (800)817-5292

Inyo (800)841-5011

Kern (800)991-5272

Kings (800)655-2553

Lake (800)900-2075

Lassen (888)530-8688

LosAngeles–TriCity (800)854-7771

Madera (888)275-9779

Marin (888)818-1115

Mariposa (888)549-6741

Mendocino (800)555-5906

Merced (888)334-0163



Modoc (800)699-4880

Mono (800)687-1101

Monterey (888)258-6029

Napa (800)648-8650

Nevada (888)801-1437

Orange (800)723-8641

Placer (888)886-5401mainline

(866)293-1940

Plumas (800)757-7898

Riverside (800)706-7500

Sacramento (888)881-4881

SanBenito (888)636-4020

SanBernardino (888)743-1478

SanDiego (888)724-7240

SanFrancisco (888)246-3333

SanJoaquin (888)468-9370

SanLuisObispo (800)838-1381

SanMateo (800)686-0101

SantaBarbara (888)868-1649

SantaClara (800)704-0900

SantaCruz (800)952-2335

Shasta (888)385-5201

Sierra (877)-332-2754

Siskiyou (800)842-8979

Solano (800)547-0495



Sonoma (800)870-8786

Stanislaus (888)376-6246

Sutter/Yuba (888)923-3800

Tehama (800)240-3208

Trinity (888)624-5820

Tulare (800)320-1616

Tuolumne (800)630-1130

Ventura (866)998-2243

Yolo (888)965-6647


• MentalHealth&SubstanceUseDisorderServicesInformationNoticeNo.16-063:SubstanceUseDisorder(SUD)TreatmentServicesforYouthinCalifornia

• MentalHealth&SubstanceUseDisorderServicesInformationNoticeNo.16-061:ClarificationonMentalHealthPlanResponsibilityforProvidingMedi-CalSpecialtyMentalHealthServices


Mental/BehavioralHealthServicesBrainstormingFormCountyorAgency:

RoleinMental/BehavioralHealthforfosterchildren:

CountyMHPProvider’sNameandContactInfo:OtherUsefulPartners’NamesandContactInfo:Agencystrengthsandresources:

Strengthsandresourcesoutsidetheagency:

Whatgaps/needsareleftafterconsideringthesestrengthsandresources?


Whatinformaltreatmentoptionsareavailabletochildrenandyouthservedbyyouragency?

Aretheseoptionsculturallysensitive?Safeforpotentiallytraumatizedchildren?Diverse?

Whatinformaltreatmentoptionsdoyouwishyouhadaccesstoforyourchildrenandyouth?

Whatformaltreatmentoptionsareavailabletochildrenandyouthservedbyyouragency?

Aretheseoptionsculturallysensitive?Trauma-informed?Diverse?

Whatformaltreatmentoptionsdoyouwishyouhadaccesstoforyourchildrenandyouth?

Whatcanyoudotoincreasethequalityanddiversityoftreatmentoptions?Whocanyouasktohelpdevelopneededresources/services?Canyoupartnerwithanotheragency/entityalreadyengagedinthiswork?Whatisyournextstep?


Segment6:PsychotropicMedication

FosterYouthMentalHealthBillofRights1. Fosteryouthhavetherighttoreceivementalhealthservicesandsupports.2. Fosteryouthhavetherighttoreceiveinformationabouttheirmentalhealth,includingtheirdiagnosisand

availabletreatmentoptions,inawaythatiseasytounderstandandageappropriate.3. Fosteryouthhavetherighttoparticipateindecisionsmadeaboutwhatmentalhealthtreatments,services,

andmedicationstheyreceive.4. Fosteryouthhavetherighttoreceiveneededmentalhealthservicesandsupportsinatimelyfashion.5. Fosteryouthhavetherighttoreceivementalhealthservicesandsupportsintheleastrestrictiveenvironment

appropriatetomeettheirindividualneeds.6. Fosteryouthwhoaretwelveorolderhavetherighttoprivatelyseekandconsenttooutpatientmentalhealth

counselingandtreatment(exceptforpsychotropicmedications).7. Fosteryouthhavetherighttotakeonlymedicationorotherchemicalsubstancesthatareauthorizedbya

doctor.8. Fosteryouthhavetherighttobeinformedabouttherisksandbenefitsofpsychotropicmedicationsinanage

appropriatemanner.9. Fosteryouthhavetherighttotelltheirdoctorthattheydisagreewithanyrecommendationtoprescribe

psychotropicmedication.10. Fosteryouthhavetherighttogotothejudgeandsaytheydisagreewithanyrecommendationtoprescribe

psychotropicmedications.(Fosteryouthareencouragedtotalktotheirattorneyfirsttomakesuretheyouthdoesnotsaysomethingagainsthisorherinterests.)

11. Fosteryouthhavetherighttoaskformentalhealthservices,includingre-assessmentsregardingtheirdiagnosesandtheirprescriptionsforpsychotropicmedications.

12. Fosteryouthhavetherighttoworkwiththeirprescribingdoctorinordertosafelystoptakingpsychotropicmedications.

12. Fosteryouthhavetherighttobeabletocontacttheirmentalhealthtreatmentproviders.13. Fosteryouthwhoaretwelveorolderhavetherighttoconfidentialitywhenspeakingwiththeirtherapistor

doctor.Withafewlimitedexceptions,ahealthcareprovidermustgetpermissionfromafosteryouthwhoistwelveorolderbeforesharingconfidentialmedicalinformationwithothers.(Fosteryouthareencouragedtoasktheirtherapistordoctorwhatinformationwillorwillnotbekeptconfidentialandwhotheproviderisallowedtosharetheinformationwith.)

14. Fosteryouthhavearighttokeeptheirmedicalinformationanddiagnosesconfidentialandonlysharedwiththoseauthorizedtoknowthisinformationforthepurposesofarrangingfor,coordinating,andprovidinghealthcareservicesandmedicaltreatmenttotheyouth.

15. Fosteryouthhavetherighttoseeandgetacopyoftheircourtrecord.16. Fosteryouthwhoaretwelveorolderhavetherighttoseeandgetacopyoftheirmedicalandmentalhealth

records.(Afosteryouthcanrequesthisorhermentalhealthrecords,butifahealthcareproviderdeterminesthatseeingtheserecordswouldbeharmfultothefosteryouth,theycanrefusehisorherrequest.)

17. Fosteryouthhavetherighttocontinuereceivingmentalhealthtreatmentwhentheirplacementchanges,includingwhentheyaremovedtoadifferentcounty.

18. Fosteryouthwhoareinfostercareontheir18thbirthdayhavetherighttocontinuetoreceivehealthcare,includingmentalhealthservices,throughMedi-Caluntilage26regardlessoftheirincomelevel.

ThecompleteFosterYouthMentalHealthBillofRightsdocumentwithendnotesandbestpracticesisprovidedwiththesupplementalmaterialsinthisbinder.


Psychotropicmedicationinfostercare

• Non-pharmacologicalinterventionsarefirst-linetreatmentapproach.Medicationistobeconsideredonlywhenotheroptionsarenotsufficient(outsideofemergencies).

• Medicationcanbeprescribedafterthoroughassessmentidentifiesneedandcleartreatmentgoals.Keepinmindthatitmaytakemorethanonemeeting/session/cliniciantoconductathoroughassessment.

• Whennecessary,medicationisbestused:o withothersupportiveinterventionsando aspartofacomprehensivetreatmentplan

• Respectforthedignityofthechildandfamilyisaprerequisiteforalltreatment.Sciencehasyettofullydeterminetheeffectsthatpsychotropicmedicationmighthaveonthedevelopingbrainsandbodiesofchildrenandyouth,butitisclearthatsomesideeffectscanbequiteseriousandlong-lasting(Gleason,Gordon,&Yogman,2016).Consequently,thedecisiontousepsychotropicmedicationshouldbeconsideredverycarefully.Dependinguponthesymptomsachildisexperiencing,therearethreegeneralpathsforusingmedicationoutsideofemergencies:1. Medicationmightnotbeusedatallintheexampleoflearneddefianceorifsymptomsaredeterminedto

betheresultoftraumaratherthanmentalillness.2. Theteammaydecidetoincludemedicationafterotherinterventionsweretriedbutfailedtoaddressall

thesymptoms.Moderateanxietyordepressionmightbeanexampleofthisscenario.3. Medicationmaybepartofaninitialtreatmentplan,forexample,ifthechildwereexperiencingsevere

AttentionDeficitHyperactivityDisorder,acutesymptomsofdepression,orpsychosis.Ifthephysicianandchildandfamilyhavedecidedthatmedicationisnecessary,itshouldbeusedinconjunctionwithotherinterventionstosupporttheholistichealthofthechildexceptinrareemergencysituations.Incertaincases,psychosocialinterventionsarenolongerrequiredwhentheyhavealreadybeensuccessfullyemployed,butcontinuingmedicationisneededtopreventrecurrenceofsymptoms.Regardlessofwhattreatmentplanisdesigned,respectforthedignityofthechildandfamilyisaprerequisite.Alltreatmentplansshouldincludetheinputandconsentofthechildandfamily,identifyandutilizetheirstrengths,aimtoincreasetheirresilience,andprioritizetheirneeds.

Informedconsentformedication

• Expectationsareclearlyoutlinedonpg.11oftheGuidelines.

• Childrenandyoutharetobeincludedintheconsentandassentprocesstotheextentfeasiblebasedontheirdevelopmentalstage.

• Child,family,andcaregiverareinformedoftherisksandpotentialbenefitsof:

ü Proposedmedication(name,dose,effects),and

ü Alternativetreatmentsincludingtheabsenceoftreatment.

• Thoroughdiscussionofanyseriousadverseeffectstowatchforandwhenandhowtocontacttheprescriberifanythinghappens.

• PrescribersconsultwithSW/POaboutwhocanprovidelegalconsent,andreleaseofHIPAAinformation.


Limitsofmedicationinfostercare

ContinuumofCareReformTitle22makesitclearthatpsychotropicmedicationsshouldnotbeusedforthepurposesofdisciplineorchemicalrestraint.Inacutepsychiatricemergencies,chemicalrestraintmaybenecessary.Thisshouldbeextremelyrare,andveryshort-term.Additionally,youtharenottobecoercedintotakingmedicationasaconditionofgettingintoorstayinginafostercareplacement.Safeandconsistentadministrationofmedicineattheprescribedtime,frequencyanddosageisasafetyissue,andmustbeaddressedinthetreatmentplan.Ifsafeadministrationcannotbeachieved,theCourtshouldbeinformed,andmedicationshouldbereconsidereduntilsafetyconcernshavebeenaddressed.Safeandaccurateself-administrationofmedicationisideal.Ifitisnotpossibleforthechildoryouthtoadministertheirmedsthemselves,itisnecessarytoassistthem.Whenassistingachildoryouthwithadministrationofmedication,itisimportanttoconsidertheirpreferencesregardinghowandwhenheorshewouldliketotakethemedicineaslongasthosepreferencesareinlinewiththeprescriber’sinstructions.Assistonlyonechildatatimeoutsidethepresenceofotherchildren.Thishelpsprotecttheirprivacyandconfidentialityaswellaspotentiallyreducingstigmaandshamethatmayaccompanytakingmedication.Documenttheappropriateprocedureforadministrationandeveryoccurrenceinthechild’srecordincludingdate,time,anddose.

AssistingwithSelf-Administration

Self-administrationofmedicationistheidealtreatmentplan.Itensuresresponsibilityandownershipoftheprocessandcanhelpempoweryoungpeople.Sometimesthiswillbeasimpleprocess;forotheryouth,itmaybemoreofachallenge.Herearesomeideasthatmayhelp--

Makesurethattheyoungpersonyouareassistingisawareofandthoroughlyunderstandstheprescriber’sinstructionandhowtogetadditionalinformationifthereisconfusion.Goovertheplanthoroughlyandmakeparticularnoteoftheanticipatedeffects,bothpositive¾suchassymptomrelief¾andpotentiallynegative¾likesideeffects.

Regularlyreiteratetheimportanceoftakingthemedicationaccordingtotheinstructions.Itisnotenoughtosaythisonceatthebeginning.Itisimportanttoreinforcethismessagethroughoutthecourseoftreatment.Inparticular,makesuretheyouthunderstandsthatitcouldbequitedangeroustomissdosesorstoptakingmedicationwithoutthesupportofadoctor.Also,explainthattheywon’tbeabletotellifthemedicationisworkingornotunlesstheytakeitasinstructed,andthattheymaynotgetanybenefitfromthemedicationatallifitisn’ttakencorrectly.

Storethemedicationinasecurelocationthattheyouthcanaccesswhentheyneedto.Thereareobvioussafetyconsiderationstofactorindependinguponthesituation,theyouth,andthemedication.Strivetoachievethemostaccessibleandempoweringsituationfortheyouthwhilecontinuingtoensurethesafetyofeveryone.Itisimportanttokeeptrackofmedicationandtobeawarewhenrefillsarecomingup.TheCommunityCareLicensingDivisionhasspecificguidelinesforgrouphomesandotherfacilitiesregardingmedicationthatcanbefoundintheSupplementalMaterialssectionofthissegment.


Becreativeaboutsupportingyouthtostayonschedule.Colorfulcalendarsorpillboxescanhelpmaketheprocessseemlessdullorclinical.Iftheyouthisusingacellphoneorcomputeranyway,somehelpfultoolscansupporttheirself-administration.Forexample,MangoHealthisamedication-trackingappthatisdesignedlikeagame.Participantscanearnpointsforstickingtotheirschedule,andtheycanevenwinreal-worldprizes,likegiftcards,forreachingtheirgoals.MedHelperandMedCoacharetwoothermedication-trackingappsthatmighthelpkeepyouthontrackandprovidetheircaregiveranddoctorwithinformationabouthowtheyaredoing.Someyouthmayevenwanttokeeptrackoftheirsymptomsandsideeffectsusingthenotesfunctionwithintheappitself.Whensymptomsimproveandthechildisfeelingbetter,itcanbeparticularlychallengingtokeeptakingmedication.Itisveryimportantthatthetreatmentteamandthecaregiverhaveregularlyscheduledcheck-insaboutsymptomsandmedication.Youngpeopleneedsupportthroughoutthecourseoftreatment,notonlywhenthingsaredifficult.Itisimportanttolistencarefullytowhattheysayabouthowtheyfeelandwhattheywantwhenitcomestotheirownhealthcare.Youngpeopledon’talwaysknowwhatisbestforthem,buttheyarealwaystheexpertsinhowtheyfeel.Buildingatreatmentplanthatwillworkbestforeachspecificpersonrequiresthattheybepartoftheplan.Everypersonisunique,soremainopentoalltheoptions.Continueaskingquestionsandexploringuntilyoufindtherightfit.Finally,scheduleregularcheck-inswiththeyouthandmembersoftheteamabouttreatmentandsymptoms.Anddiscussallchanges,notjustthetargetsymptoms.Bereliableandconsistent.

Risks

Psychotropicmedicationsareassociatedwithanarrayofpossiblerisks.Theyvarywidelydependingupontheageanduniquecharacteristicsofindividualswhotakethem.Someoftheserisksarecalledsideeffects,meaningthatmedicationcancauseeffectsotherthanorinadditiontotheintendedones.

Individualshaveexperiencedincreasedsuicidalideation,sleepdisturbance,sleepinessandlethargyordifficultymovingaround.Somehaveexperiencedrapidweightgainleadingtoobesityandpronouncedchangesintheirbloodsugarandmetabolismsometimesleadingtodiabetes.Nervousness,restlessness,andirritabilityarealsocommoncomplaints.Headachesandupsetstomachorchangesinappetitearealsopossible.Alltheserisksshouldbemadecleartothechildandfamilywhentreatmentdecisionsarediscussed.Childrenandfamiliescannotmakeinformeddecisionswithoutbeingawareofthesepotentialrisks.TheCaliforniaGuidelinesdirecttheprescribingphysiciantoinformthechild,family,andothersinvolvedintreatmentplanningabouttherisksandbenefitsofthemedicineandofothertreatmentoptionsincludingtherisksandbenefitsofnotreatment.Rarely,individualsmayhaveadversereactionsthatcauseseriousillnessordeath.Chronicillnessandpermanentfacialorbodyticsandtremorsdosometimesoccur.Itispossibleforchildrenoryouthtobecomeaddictedtocertainmedications,andthisriskshouldbeincludedindecisionmaking.Additionalrisksarepresentwhenmedicationsarenottakenaccordingtotheinstructions.Treatmentplansshouldincludedetailsaboutsafeandconsistentadministrationofthemedication,ensuringanadequatesupplyofmedication,andasafetyplanforhowtostoptakingthemedicationshouldthatbenecessary.

Thereareappsthatcanhelpwithself-administeringmedication:

• MangoHealth• MedHelper• MedCoach


SubstanceUseandMedication

Carefulconsiderationofthechild’soverallhealthandneedsiscrucialtocreatinganeffectivetreatmentplan.Ifthechildoryouthusesun-prescribedmedications,otherdrugs,oralcohol,itisimportanttoassesstheriskofaddingapsychotropicmedication.Interactionsbetweenmedicationsanddrugsoralcoholcanbepowerfulandtoxic.Sometimes,individualsareusingdrugsoralcoholtoself-medicateandtoessentiallytreatthesamesymptomsthatthetreatmentplanisattemptingtoaddress.

Alternatively,substanceusedisorderitselfcanmimicthesignsorsymptomsofotherdysregulations.Ifthatisthecase,thatdisordermustbetreatedfirstinordertoaccuratelydiagnosisthechildoryouth.Ifbothsubstanceusedisorderandotherbehavioralhealthissuesarepresent,dualdiagnosistreatmentshouldbeprioritizedinthetreatmentplan.Thismeanstreatmentthatfocusesontheintersectionandoverlapofproblematicsubstanceuseandseriousmentalhealthneeds.

Potentialbenefits

Thebesttreatmentplanforanindividualmayincorporatemedication,whichhasthepotentialtoimproveschoolperformanceandabilitytoconcentrate,decreasetheexperienceofanxietyorworry,reducesymptomsofdepression,improveoreliminatefrequentphysicalpainorsomaticcomplaints,reduceoreliminatenightmaresandothersleepdisturbance,andlimitexcessiveaggressionortempertantrumsandimprovemood.Thesepotentialbenefitsaretobeweighedagainstthepotentialriskswhendecidingwhetherornottoincludemedicationinachildoryouth’streatmentplan.Forchildrenandyouthinfostercare,notallofthesepotentialbenefitsarefullybackedbyevidence(AmericanAcademyofPediatrics,xxx).Therefore,itisvitalthattheintroductionofmedicationsisincremental;beginningwithalowdose,andslowlyadjustedwhilecarefullytrackinganypositiveornegativeeffects.Itisimportanttonotethatallthebenefitsdescribedherearealsopotentiallyachievablewithouttheuseofpsychotropicmedicationdependingontheindividual.Caremustbetakentorefrainfromviewingpharmaceuticalsastheonlyoptionorasacure-allforeveryone.

AttentionDeficitandAnxiety/DepressionMedications

AttentionDeficitandHyperactivityDisorderorADHD:Arelativelycommondiagnosisforchildrenandyouth.PsychomotorstimulantslikeRitalinandAdderallareoftenprescribedtotreatthesymptomsofADHD.Theycanhelpchildrentoconcentrateandcontrolhyperactivity.Commonsideeffectsincludedecreasedappetiteorstomachdiscomfortandpoorsleep.Non-stimulantssuchasStratterahavethesamebenefitsaswellasdecreasedcompulsivebehaviors.Thecommonsideeffectsarealsosimilar—stomachdiscomfortandpoorsleepalongwithheadache.

AnxietyandDepression:Symptomsrelatedtoanxietyanddepressionmayalsobeaddressedwithmedication.SelectiveSerotoninReuptakeInhibitorsandAtypicalAntidepressantssuchasProzac,Zoloft,Celexa,WellbutrinorLexapromaydecreasedepressivesymptoms,improvemood,anddecreaseanxiety.Theycancausenausea,anddisturbsleep.Theyalsoposeanincreasedriskofseizureandanincreasedriskofsuicidalideationespeciallyinadolescents.Thesesideeffectsmayincreasewithirregularadministration,soshouldbecarefullyconsideredifproperadministrationisdifficultorunlikely.


MoodandPsychoticDisorderMedications

Mooddisorders:ToaddressthesymptomsofmooddisorderssuchasBipolarDisorder,doctorsprescribemoodstabilizerslikeLithiumorAnticonvulsantslikeDepakote.Thesemedicationsmayimproveorstabilizemoodsymptomsandimproveimpulsecontrol.Lithiumcancausedrymouth,tremor,stomachdiscomfort,weightgain,memoryproblems,thyroidandkidneyproblems.Anticonvulsantsalsohaveseriouspotentialsideeffectssuchasdrowsiness,nausea,seriousrashes,liverproblems.Periodiclabtestsandcarefulmonitoringbyaphysicianisnecessarywhilechildrenoryoutharetakingthesemedications.

Psychoticdisorders:Antipsychoticmedicationsareapotentclassofpsychotropicmedications.Theyaredividedintotwocategories,NewerandOlder.Theyareusedtotreatveryserioussymptomssuchashallucination,delusions,anddisorderedthinking.Theycancauseextrapyramidalsideeffects(EPS)suchasshakiness,drooling,andstiffness.Theyoftencauserapidweightgain,heartandbloodirregularities,permanentticsandtremors,anddiabetes.

Medicationstoaddresssideeffects

Manypsychotropicmedicationshavethepotentialtocausesleepdisturbance.Doctorsmayprescribesedativesorhypnotics,andsometimessleep-promotingmedicationslikeBenadryltohelpchildrensleep.Thesemedicationshavethepotentialtobehabit-formingandcancauseadditionalsideeffects.

Theseveresideeffectsfromantipsychoticscanbetreatedwithanticholinergicmedications.Thesecanreducetheshakiness,drooling,andstiffnessassociatedwithEPS.

Itisimportanttonotethatmultiplemedicationsandusingmedicationtotreatsideeffectsofothermedicationisnotrecommendedpractice,butdoesoccur.Childrenwithseveralsimultaneousprescriptionsareatincreasedriskforadverseeffects.Useofmultiplemedicationsshouldbecarefullymonitoredbythefamilyandthephysician.Aswithallmedication,thesedecisionsshouldbecarefullyanalyzedbytheentiretreatmentteamtoensurebestoutcomesforthechild.

SideEffects

Safety:Ifsideeffectsaresuspectedoridentified,safetyisthepriority.Followallemergencymedicalproceduresifnecessary,andtakenecessarystepstoensurethesafetyofthechild.

• Consultwiththeprescribingphysicianimmediatelytodetermineifchangesneedtobemade.• Donotallowthechild/youthtosimplystoptakingmedication.Thereisusuallyaprotocolforweaning

offpsychotropicmedications,anditisvitaltofollowthosedirections.• Ifdoseorschedulechanges,followupwiththerequiredCourtdocumentsanddocumentthechange

inthehealthrecordandthechild’sfile.

Planahead:Findoutwhatsideeffectsarepossiblewhenthetreatmentplanwithmedicationismade.Haveasafetyplancreatedintheeventthatsideeffectsemerge.Itisimportanttobeawareifthereareanyknowninteractionswithotherdrugsoralcoholaswellasstepstotakethatmightreducethelikelihoodofsideeffects.

• AppendixBoftheCAGuidelinesistheprimarydocumentCDSShasidentifiedforreferenceaboutspecificmedicationsandtheparametersfortheiruse(dosage,sideeffects,potentialinteractions,etc.)LACountyiskeepingthisdocumentup-to-dateandpubliclyavailableontheirwebsite.


• Youcanlearnmoreaboutpossiblesideeffectsbyresearchingonsiteslikemedlineplus.govorfindingthepackageinsertfortheprescribedmedication,whichareusuallyavailableonline.

DocumentingSideEffects

• Socialworkersandprobationofficersmustensurethatmonitoringoccurs.ItmaybethePHNorcaregiverwhodospecifictasks,butthesocialworkerisresponsibleformakingsureithappensasoftenandthoroughlyasnecessary.

• Socialworkersandprobationofficersdon’tneedtobetheexpertsinknowingallthedetailsofthisinformation,buttheymustcollectitfromthedoctorsandhealthprofessionalswhoareexpertsandmakesurethatthechildandcaregiverandfamilyhavereceivedtheinformationandunderstandit.

• Regularlyaskthechildoryouthtodescribetheirexperiences—bothphysicalandemotional—sincetakingthemedication.Askthemtocomparethoseexperiencestohowtheyfeltbeforetakingmedication.Thisassessmentshouldoccurthroughoutthedurationofthetreatmentassideeffectscandevelopatanytime.

• Ifdevelopmentallyappropriate,thechildshouldbeawareofeffectstowatchoutforandwhotheyshouldtelliftheyexperiencesomethingnew.

• Theprescribingphysicianshouldmakecleartothetreatmentteamhowtheycanbecontactedshouldsomethingarise.

• Therecommendeddoseshouldbeageappropriate.ThismaybedifficulttodetermineastheFDAhasnotapprovedmanyofthecommonpsychotropicmedicationsforusewithchildrenoryouth.

• AppendixAoftheCaliforniaGuidelineshasageparameters.Evenifthedosefallswithinacceptableguidelines,itmaybetoomuchortoolittleforaspecificindividual,soitisimportanttomonitortheirresponses.

• Itisalsoimportanttocheckwiththefamilyandcaregiversofthechildoryouthtoseewhethertheyhavenoticedanychangesinthechild’smood,behaviororappearance.Schoolpersonnel,friendsfromchurchandthecommunitymayalsobeabletoidentifyiftherearechangesinthechild’sbehaviorintheseotherenvironments.

• Collectivevigilanceandfrequentcommunicationcanhelpidentifyandaddresssideeffectsfrompsychotropicmedications.


• FosterYouthMentalHealthBillofRights• QuestionstoAskAboutMedicationsBrochure• AlamedaCountyTransition-AgeYouthSideEffectInformationalCards• AmericanAcademyofChildandAdolescentPsychiatry—FactsforFamilies:WeightGainfrom

Medication,PreventionandManagement• MedicationMonitoringChecklist• CommunityCareandLicensingResourceGuidetoMedicationsinGroupHomes• SampleSafetyPlan


Activity:QuickRolePlay

1. Six-year-oldElizabethhasrecentlybeenprescribedRitalintoaddressrestlessness.Hertreatmentplancallsforevaluationofsymptomsandsideeffects.

2. Juliusis17yearsoldandabouttotransitionoutoffostercare.HecurrentlytakesaSelectiveSerotoninReuptakeInhibitor(Celexa)foracuteanxiety.Hisfostermotherisconcernedthathewillstoptakingitonceheleavesherhome,andwouldlikehimtohaveasafetyplan.

3. Afterherappointmentwiththedoctor,Phoebehassomequestionsabouttherisksandbenefitsoftakingtheantipsychotic(Zyprexa)thatherdoctorisrequestingfromthecourttoaddressherimpulsivityandaggression.Sheis15yearsoldandlivesinagrouphome.

4. CharlotteistenyearsoldandshehasbeentoseehertherapistweeklyforthreemonthsandistakingVistariltohelphersleep.Shefeelsthathersleepisbetter,butthetherapyismakingthingsworse,andtheconversationsshehasmakehermoreupset.Shewantstostopgoing.

5. Derrickisafosterparent.Hewastoldbythedoctorathisfosterson’slatestappointmentthatAdderalldoesnothaveanysideeffects.Hiseight-year-oldfostersonwasalreadytakingitwhenhecametoDerrick’shome.

6. TheApplicationforSamtostarttakingZolofttoaddresssymptomsofseveredepressionwasapprovedbythecourt.Discusstheriskofsuicidalideationrelatedtothisdruganddecideaboutsafetyplanning.Samis13yearsold.


Segment7:UsingtheCaliforniaGuidelines

WhataretheGuidelines?

TheCaliforniaGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCareisadetaileddocumentandfourappendicesthatwerecreatedandassembledcollaborativelybyCDSSandDHCS.

• Sharedvalues,expectations,andprinciplesofpsychotropicmedicationuseinfostercare.• Designedtobeanadvocacytooltohelpguidenon-medicalprofessionalswhenworkingwithdoctors

andpsychiatristsandothermedicalpersonnelorserviceprovidersSeveralimportantgoals:

• Increasedvisibilityofstrengthsandneedsofchildrenandyouthwithemotional,cognitive,and/orbehaviordysregulation

• Reductionofsocialstigmaduetodysregulation• Promotingbestpracticesinthestate’scommitmenttoprovidebothformalandinformal

mental/behavioralhealthservicestochildrenandyouthincare.Outlinesexpectationsabout:

• Treatmentplans,assessment,anddiagnosis• Whatprescribersshouldconsiderforcertainactivities

o Beforeprescribingo Whenprescribingo Whenevaluatingwhetherornotatreatmentiseffectiveo Prescribinginanemergency

FourAppendiceswithtools:A:PrescribingStandardsbyAgeGroupB:Parametersfordoserangeandschedule(LACounty’sParameters3.8)C:ChallengesinDiagnosisandPrescribingincludingrecommendationsD:DecisionTreeforPrescribing

PrinciplesandValues

TheGuidelinesoutlinethesharedprinciplesandvaluesofCDSSandDHCSregardingtheuseofpsychotropicmedicationwithchildrenandyouthinfostercare.

• Alwaystopromotesafety,permanence,andwell-being• Realpartnershipswiththeimportantpeopleinthechild’slife• Workingfromachild-centered,strength-basedperspectivetocreatetrulyindividualizedtreatment• Providingthehighestqualityofcarethatisintegratedwithinthechild’scommunityandin

collaborationwithanyhelpfulpartners.• Psychotropicmedicationisnottobeemployedasthesoleintervention(exceptinextremelyrare

caseswhentreatmentwithmedicationissuccessful,butneedstobecontinued),butratheraspartofarobustoveralltreatmentstrategyemployingbothformalandinformalinterventions.

TreatmentPlan

Atreatmentplanisthedetaileddescriptionofservices,supports,andtreatmentsthatwillbeemployedtoeliminateorreducethechildoryouth’sidentifiedsymptoms,emotionaldistress,and/orproblematic


behaviors.Itisthedocumentthatdescribeshowtheteamwillattempttoimprovethingsforthechild.Treatmentplanningisalwaysdonecollaborativelywithchildrenandtheirfamilies,whetherornotaChildandFamilyTeamiscreated.Amulti-disciplinaryteamfunctionsverysimilarly,oranevenless-structuredsupportivegroupcanbesuccessfulincreatingaqualitytreatmentplan.Theimportantthingistoincorporatediverseperspectivesthatbuildaroundtheuniqueresources,abilities,strengths,andneedsofeachspecificchildandhisorhernaturalsupportnetworkandcommunity.Ifachildistooyoung,oriftherearedevelopmentalorprotectiveissuesinthecasethatpreventcollaboration,everyeffortshouldbemadetoinvolvearepresentativetospeakonbehalfofthechildindecisionmakingmeetings.Toeveryextentpossible,thechildortheirrepresentativeshouldbeincludedinalltheplanning,review,andre-assessmentofthetreatmentplan.AccordingtothebestpracticeoutlinedintheGuidelines,treatmentplansincludethefollowing:• Thechild’sdiagnosisand/oroutlineofemotional/cognitive/behavioraldysregulationbasedonthechild’s

historyofabuse,neglect,and/orremovalfromthehome;• Adescriptionofthechild’sbaselinestrengthsandneeds;• Targetsymptomsasagreedtobythechild,family,andteammembersandexpressedinclear,everyday

language;• Short-andlong-termtreatmentgoals;• Interventions,includingevidence-supportedtreatments,psychosocialinterventions,substanceabuse

preventionortreatment,casemanagement,informalmentalhealthservices,educationalorbehavioralservices,extracurricularandrecreationalactivitieswithstartdatesandanticipatedduration;and

• Aclearandspecificplanforperiodicreviewandreassessment.KatieA.plansmustbereviewedatleastevery90days.

• UpdatedmedicationtreatmentplansmustbecommunicatedasanattachmenttotheJV220formforthecourt,aswellassharedwiththechild/youth,family,caregiver,andchildwelfaresocialworkerand/orprobationofficerfordistributiontoallnecessarypartiesinaccordancewithHIPAA.

Thesearethebasicsofhigh-qualitytreatmentplanning.Plansshouldseektoutilizeavarietyofinterventionstoaddresstherootcausesofdysregulationwhetherthatcauseistraumaormentalillnessoracomplexinteractionofmultiplefactors.Alleviationofspecificsymptomsisimportant,butisonlyPARTofacomprehensivetreatmentplan.Includinginterventionsthatarebackedbyevidenceiscrucial.Plansshouldseektobecomprehensiveandtreatthewholechildnotsimplytheperceived“problems”withthechild’sbehaviororfunctioning.HIPAAcomplianceisasimportantintreatmentplanningasitisinallareasofhealthcare.

NeedsAssessment

Childrenwhohaveemotional,cognitive,and/orbehavioraldysregulationfromtrauma,mentalhealthconcerns,orforotherreasonsrequireanddeserveatreatmentplanthatcontainsavarietyofinterventionstoalleviatetheirsymptomsandtopromotetheirsafetyandwell-being.Thefirststepinthatprocess,isahigh-quality,trauma-informed,child-centeredassessment.

Aswementionedbefore,anyassessmentofchildrenoryouthinfostercareshouldbeconductedbyalicensedpractitionerwhoisinformedabouttheconditionsandeffectsoftrauma.Andshouldthoroughlycoveralloftheseitems:

• PhysicalANDmentalstatusexaminations,


• Identificationoftargetsymptomsandthegoalsoftreatment,• Aclearplanandtimelineforre-assessmentandhowmonitoringprogresswilloccurandwhois

responsibleforwhichpartsoftheplan,and• Aclearrisk/benefitanalysisofeachtreatmentintheplanincludingtherisksandbenefitsofno

treatment

PhysicalExamination

Theresultsofthemostrecentphysicalexaminationofthechild—withinthepastyear—shouldbereviewedaspartofthetreatmentplanningprocess.Theseresultswillbeusedtoruleoutmedicalconditionswhentheymaycontributetoorcausethepresentingsymptoms,andtoprovidebaselineinformationformonitoringpotentialsideeffects.Asappropriate,thetreatmentteammayconsiderapregnancytestorsubstanceusescreen,asbothcouldhaveseriousimplicationsforwhetherornottoprescribepsychotropicmedication.Theseinitialexaminationsareparticularlyimportantforfollow-upandmonitoringsideeffectsbecausewithoutabaseline,itmaytakelongertonoticechangesthatmayindicatedangerousdevelopmentsorsideeffectsthatneedtobeaddressedquickly.

MentalHealthExamination

Theexaminationofthechild’smentalstatusshouldbedevelopmentallyappropriate.Anyapplicablediagnosisshouldbeinlinewithprofessionalstandardsandbesupportedbysufficientdocumentationtoruleoutotherpossiblediagnoses.Theassessmentshouldidentifythetargetsymptomsandgoalsoftheselectedtreatment,alongwithatimelineforwhenresultsshouldbeexpectedandhowlongthetreatmentisintendedtolast.Itisimportanttosharetheresultsofthisassessmentwiththechildandtheirsupportnetwork,butitisespeciallyimportanttosharethegoalsandtargetsymptomswiththem.Inthisway,everyonewillunderstandwhatthetreatmentisforandwhattoexpect.Itisalsoimportanttoconsiderifthegoalsarefocusedontreatingtheunderlyingemotionaldistressthatthechildisexperiencing,andtorefocusthemontoalleviatingthatdistressifnecessary.Regularre-assessmentisanexpectedactivity.Thetreatmentteamshouldmonitorsymptoms,sideeffects,andthechildandfamily’sneedsanddesires.Alltreatmentplansshouldexplicitlyincorporatearisk–benefitanalysisthatcomparesatreatmentplanwithoutmedicationtothepotentialbenefitsandrisksofaddingaprescription.

GoalsandTargetSymptoms

Tremendouslyimportanttothequalityofthetreatmentplanistoidentifyspecificsymptomsthatthetreatmentisintendedtoaddress.Thisiswherethevoiceandopinionofthechildiscrucial.Treatmentplansshouldnotjusttargetthebehaviorsthatacaregiverfindsproblematic,butattempttoaddressthecoreissuesandsourceofdysregulation.Ideally,NOTjustmedicationwillbeusedtoreachthegoalsstatedhere.

InformedConsent

Itisimportanttoobtaininformedconsentforanyandalltreatment,notjustformedication.Theroleofthesocialworker,publichealthnurse,and/orprobationofficeristoensurethatthechildunderstandstheirrightsandtherisks/benefitsoftheproposedplan.Useterminologythatisclearandeasytounderstand.Informationshouldbeprovidedinthechildandfamily’sprimarylanguageandinwrittenform,ifpossible.InCalifornia,achildtheageof12andoverhastherighttoconsenttotreatmentandtherighttorefuseconsent.Theassent,oragreement,ofchildrenyoungerthan12isveryimportant.Thesocialworkerisresponsibleforknowingwhoisandwhoisnotabletoprovidelegalconsent.


GuidelinesforPrescribing

• StartLow,GoSlow—tobestmonitoreffectivenessandsideeffects,itisimportantthatpsychotropicmedicationsareintroducedoneatatime,andstartingfromthelowestrecommendeddose.Thedosecanbeincrementallyincreaseduntilthelowesteffectivedoseisidentified.

• On-labelUse—preferenceshouldalwaysbegiventomedicationsthatareFDAapprovedfortheagegroup,diagnosis,anddoseforwhichitisbeingprescribed.Medi-Calhasalistofbrandsandgenericsthatshouldbeusedwhenpossible.

• Ifchangesarenecessary,theyshouldbemadetoonemedicationatatime.Itisverydifficulttodeterminewhatisworkingandwhatisn’tifmultiplechangestakeplaceatonce.

• Ifyouthinktheremaybetoomuchinaprescribeddoseortoomanymedicationstotal,talktoapsychiatricspecialistatyourcounty.Donotassumethatthedoctorisright.It’sokaytogetasecondopinion.


• CaliforniaGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCareandAppendices

• AllCountyInformationNoticeNo.1-0514:SharingInformationwithCaregivers• AllCountyInformationNoticeNo.1-36-15:ImprovingSafetyforChildreninFosterCareReceiving

PsychotropicMedications


Activity:GetFamiliarwiththeGuidelines

1. Whatpagewillhelpyoudeterminetheprescribingstandardsforachildwhois13yearsold?

2. WhatareallthepotentialcomplicationsandsideeffectsforSerotonergicAntidepressants?

3. AccordingtotheGuidelines,whoisresponsibleforobtaininginformedconsent?

4. Sometimesdoctorsprescribemedicationtotreatasymptomotherthanthemedication’sindicateduse.Thisiscalledofflabelorblackboxprescription.WhereintheGuidelinescanyoufindinformationaboutthechallengeofoff-labelor“blackbox”prescription?

5. WhatarethethreesectionsofthePrescribingAlgorithm(DecisionTree)?Follow-upquestion,whatisSectionCactuallyusedfor?

6. HowdotheGuidelinesdocumentsconnectwiththeJV-220process?


Segment8:WrapUpandEvaluation

WrapUpQuestions—

• IsthereanythingmissingfromtheGuidelinesthatyouthinkmighthelpyouwithpsychotropicmedicationinfostercare?

• Whataboutworkingfromatrauma-informedperspectiveresonateswithyouthemost?

• Whatdoyouneedtoincorporatethisperspectiveintoyourwork?

• Anyremainingquestions?

Ombudswoman’sOffice

Ifyouhaveanyquestionsorconcernsaboutpsychotropicmedicationinfostercare,theFosterCareOmbudswomanofCaliforniahasagreedtohavehercontactinformationincludedinthistraining.

Herofficeisavailableforsupportandresourcesonthistopic.

Toll-freephone:1.877.846.1602

E-mailaddress:[email protected]

CourseEvaluations

Thankyouforyourtimeandattentiontothisimportanttopic.


Resources

• CalSWEChostsatoolkitforthechildwelfare/mentalhealthlearningcollaborativethathasanarrayoftrainingandimplementationresourcesregardingthedeliveryofbehavioralhealthservicestochildreninfostercare.Thetoolkitalsoprovidescontactinformationforpartneringorganizationsthatprovidetrainingandtechnicalassistance.ThetoolkitwasdesignedforusebyCaliforniacountiesandregions,andisalsoaccessiblebythepublic:http://calswec.berkeley.edu/toolkits/child-welfare-mental-health-learning-collaborative-katie.Withinthistoolkit,youmayhaveparticularinterestintheresourcesfoundinthewebpagesfor“TeamingTools”and“EngagementTools.”

• TheChildren’sBureaupublishedMakingHealthyChoices:AGuideonPsychotropicMedicationsforYouthinFosterCarein2012https://www.childwelfare.gov/pubs/makinghealthychoices/andthecompanionguideforcaregiversandcaseworkerscalledSupportingYouthinFosterCareinMakingHealthyChoices:AGuideforCaregiversandCaseworkersonTrauma,Treatment,andPsychotropicMedicationin2015https://www.childwelfare.gov/pubs/mhc-caregivers.Theyarebothvaluableresourcesonthetopicsmostrelevanttothistraining.

• SubstanceAbuseandMentalHealthServicesAdministration’sConceptofTraumaandGuidanceforaTrauma-InformedApproach,July2014http://store.samhsa.gov/shin/content/SMA14-4884/SMA14-4884.pdf

• AmericanAcademyofPediatrics’HelpingFosterandAdoptiveFamiliesCopewithTrauma(2015)https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Documents/Guide.pdf

• TheNationalChildTraumaticStressNetwork’stoolkitswww.NCTSN.org

• AlamedaCountyTransition-AgeYouthandshareddecisionmakingtools:http://www.acbhcs.org/MedDir/decision_tools.htm

• http://www.dhcs.ca.gov/individuals/Pages/MHPContactList.aspx

• TheCaliforniaInstituteforBehavioralHealthSolutions(CIBHS)offerstrainingresourcesthatsupportKatieA.implementation,includingwebinarsforpreparingyouth,parents,andprofessionalsforparticipationintheChildandFamilyTeam(CFT)andteammeetings:http://www.cibhs.org/katie-implementation-technical-assistance-and-training


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