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Authorization of the Use of Antipsychotic Medications for Youth in Foster Care.

 

(This policy will be located in IV-A Service Authorizations and is guided by the philosophy and general procedures, 1 and 2, under that policy, and located in  Sec. II. #3. Mental Health and Substance Abuse Services.)

 

PHILOSOPHY  

Services provided to clients of the Department of Health and Human Services (DHHS) Child Welfare Division are based on assessed need, agreed upon goals, and measurable outcomes. Clear timeframes for evaluating outcomes and progress are in place. Services are based on client informed choice and concurrence.

 

GENERAL PROCEDURES

 

1.Rights of clients of services authorized by Child Welfare Services.

All clients, including children and youth, have the right to participate in all service decisions, review their treatment, case or service plan, refuse any service unless mandated by law or court order and be informed about the consequences of refusal or disengagement with services. The client of mental health services should be provided with a copy of the Rights of Recipients of Mental Health Services published by DHHS. Clients must be informed of their right to choice in the selection of a service provider qualified to meet the assessed service or treatment need. Services are to be provided to meet the assessed need and should not go beyond the scope of that need unless requested by the client. The client is to be informed prior to any engagement in services of their rights regarding confidentiality and privacy protections by the provider. DHHS staff must comply with the DHHS confidentiality policy.

 

Any client denied or discharged from services or treatment must be informed of agency procedures for expressing and resolving grievances.

 

2.Case Planning is the Primary Context for Service Authorization

Medical, dental, mental health and substance abuse services shall be authorized in the context of a plan to provide for the safety, permanency and well being of a child and/or to address the threat or risk of abuse and neglect by a person responsible for the child. In completing any plan in the child welfare context caseworkers shall obtain and consider impact on the child, relevant evaluations, medical reports and therapist’s progress reports.

 

 

3.Authorization of the Use of Antipsychotic Medications for Youth in Foster Care.

 

Antipsychotics are first line treatments for psychosis and manic episodes and second line treatments for aggression or dangerous behavior or in the context of Autism Spectrum or Intellectual Disability.

 

Most of the antipsychotics prescribed currently are “second generation antipsychotics”, also known as atypical antipsychotics and include:

Clozapine/Clozaril

Risperidone/Risperdal

Zyprexa

Seroquel

Geodon

Abilify

 

The above named medications will account for over 90% of prescribed antipsychotics. Some youth may be prescribed first generation (also known as typical) antipsychotics. There are many of these; the most common (generic/brand names) are:

Chlorpromazine/Thorazine.

Haloperidol/Haldol

Perphenazine/Trilafon                           (Medications listed may be subject to

Trifluoperazine/Stelazine                                   change over time.)

Thiothixene/Navane

Molindone/Moban

 

4.Clinical Indications

It is crucial to ensure that antipsychotic medications are being used only when clinically indicated—i.e., when the likely benefit from their use would outweigh their very substantial risk. When these medications are used, proper monitoring of their metabolic side effects must take place. Side effects include weight gain, increased risk of diabetes and changes in serum cholesterol. These metabolic changes, in all likelihood, increase the chances that youth will have serious medical problems later in their adult life. The Child Welfare Consent Worksheet is to be followed when antipsychotic medications are currently prescribed or considered. (Appendix A.)

 

5.Casework Review and Responsibilities

Prior to any consideration of medication to address a child’s mental health needs the treating provider must be given a full description of the circumstances of the child that follows a Casework Review:

A Casework Review must be complete and shared with the prescriber and   include answers to the following questions:

.Are psychosocial or environmental factors contributing to the youth’s symptoms?

 

.What actions/interventions are being done to promote stability and foster strong connections/emotional bonds with caretakers?

 

The caseworker is required to be present in person or by phone at the appointment with the prescriber at the first appointment and every three months following or as requested by the caregiver or provider to attend.  

 

When antipsychotic medications are considered, the caseworker will review with the child the youth guide, Making a Choice. (Appendix B.)  A full description of risks and benefits of medication is given to youth in age appropriate language through interactive discussion of the guide.

1.Youth 14 and over must consent unless there is an emergency (imminent danger of bodily harm to youth or others) otherwise youth over 14 can only be prescribed medication that they, their caretaker and their prescriber all consent to.

2.Consent must be given willingly and may not be obtained through coercion, as detailed in Rights of Recipients. In serious or imminent situations consent may be given if circumstances meet the definition of urgent as outlined in the Consent Worksheet:

 

A.Definition of urgent

i.  Youth likely to hurt self or others.

ii.  Youth likely to lose his/her living and/or school placement that would be disruptive to their well-being.

B.If yes, consent can be given for 60 days.

 

Consideration should be given to discussion with the prescriber, use of the Family Team Meeting to further review options when a youth does not wish to give consent. The youth should be given the ability to have control and the decision could be revisited at a later date if necessary.

 

 

6.Reviews

Reviews of children who are prescribed antipsychotics and who are being considered for them shall occur with Child Welfare (CW) staff and Children’s Behavioral Health (CBHS) staff. These review meetings shall be coordinated by a designated child welfare supervisor and the CBHS clinical care specialist for the district. Case by case consultations may also occur as needed, especially in circumstances of a child under seven (7) or when there are severe reactions to the medication (i.e. behavioral escalation, lethargy, bizarre thoughts, severe weight gain, TD)

  Those who attend monthly consults shall include:

•CW supervisors within district

•Caseworkers who are involved with cases being presented/reviewed.

•Clinical Care Specialist of that district

•Medical Director, CW Program Administrator and/or CBHS Team Leader at district discretion.

 

7.Continuation of antipsychotics

 

 

As with any medication, a plan must be in place for what steps are necessary when the medication is to be ended. When a child transitions to a new placement, it is the responsibility of the caseworker to identify for the new care provider the medications the child is taking and who the prescribers are. The prescribers must also be informed if a child is moving to another location and there will be a transition in providers to be ensured that the plan meets the specific needs of the child and there is consistent follow up and monitoring.

 

 

Appendix A. Consent Worksheet

 

Antipsychotic Medication Consent Worksheet

This worksheet is intended to give each party a better understanding of the risks and benefits of antipsychotic medications, identify questions for consideration and support informed decisions.

 

Mark with “Y” for Yes and “N” for No

 

1.  ____  Youth has been provided the Making a Choice youth discussion guide which caseworker or caregiver has reviewed with youth.

 

2.  ____  Full description of risks and benefits of medication is given to youth in age appropriate language by the provider.

 

 a. ____  Youth 14 and over must consent unless there is an emergency (imminent danger of bodily harm to youth or others).

 b. ____  Consent must be given willingly and may not be obtained through coercion, as detailed in Rights of Recipients.

 c. ____  Youth under 14 should assent to use of medication.

 

3.  ____  Yes ____  NO  Is this an urgent situation?

 

         a.  Definition of urgent  

i.____ Youth likely to hurt self or others

ii.____ Youth’s symptoms likely to cause loss of his/her living and/or school placement that would be disruptive to their well-being.

 c.  If no, steps #4 – 11 below must be followed in order for consent to be appropriate.

 d.  Consent for urgent situations may not be given for consecutive 60 day periods without special permission by Program Administrator.

 

4.  ____  The Casework Review must be complete and shared with prescriber:  

 a.  Are psychosocial or environmental factors contributing to the youth’s symptoms?

 

 b.  What actions/interventions are being done to promote stability and foster strong connections/emotional bonds with caretakers.

 

5.  ____  Provider states the youth had a complete psychiatric evaluation within the past year; or psychiatric evaluation is not needed due to provider history and knowledge of client. If the youth has been hospitalized within the past year, the admission evaluation counts as a psychiatric evaluation.

 

6.  ____  Is the target symptom psychosis or a manic episode?

 a. ____  If yes, consent is appropriate

 

i.   Please list DSM-IV symptoms of psychosis or manic episode that the provider has stated_______________________________

ii.   Skip to item 8

 

 b. ____  If no, continue to item 7

 

7.  ____  Is the target symptom aggression and/or severe emotion dysregulation?

a. For youth with Autism Spectrum Disorders:

i.  ___  A Functional Behavioral Assessment, if available, has been completed, and its recommendations have been acted upon.

b.For aggression without autism:

 

8.  ____  Quantify, frequency, and severity (0-10) of most clinically relevant symptoms have been rated by the provider; this will be a baseline measure that will aid in evaluating response to medication.

 

9.  ____  Baseline measurements have been taken: weight, Body Mass Index (BMI), BMI percentile, pulse/blood pressure, Abnormal Involuntary Movements Scale (AIMS)

 

10.____ Baseline labs have been done: fasting lipids, fasting glucose.

 

11.____ Has the provider discussed diet and exercise recommendations with caregivers?

 

12  For continuation of antipsychotics

a. ____ Have risks and benefits of continuation been considered?

i.___ Are BMI and BMI percentile being tracked?

ii.___ Are pulse/blood pressure, fasting glucose, and fasting lipids being followed?

iii.___ Are frequency and severity of target symptoms being tracked?

 

 b. ____ If antipsychotic is being used for aggression:

 

i.Has youth’s aggression substantially improved?

ii.____ If yes and antipsychotic has been used for 6 months, has the discussion been held with the provider to strongly consider an attempt to decrease the dose and move toward discontinuation?

 

 

Appendix B.    Youth Guide

This guide was made possible by a partnership of:

Youth MOVE Maine, The Youth Leadership Advisory Team (YLAT)

And Maine’s Department of Health and Human Services (DHHS)

www.youthmovemaine.org         www.ylat.org

 

 

Making A Choice:
What Kinds of Things Should You Know About
Antipsychotic Medication?

 

Decisions about your mental health treatment are  very important. Antipsychotic medication is one treatment option that can be very effective in treating a variety of issues and may be recommended to help a person gain control of his or her life while the cause of the problem is being addressed.

 

Antipsychotic medication may be recommended when a person is struggling with hallucinations, delusions, mood disorders or aggression that gets in the way of daily life. There are also risks to taking antipsychotic medication and this guide will help you explore the risks and benefits so you can make an informed decision with your doctor and caregiver.

 

It’s important that you know that medication is just one tool that can help you overcome mental health challenges. You have the right to know all your treatment and support options. Other treatment options may include different medications, exercise, diet, meditation and counseling. You, your doctor, and your caregiver should discuss all your treatment options and create a plan that works for you.

 

There are risks to taking antipsychotic medications, which may include weight gain, tiredness, changes in blood pressure, movement disorders (i.e. Tardive Dyskinesia), high cholesterol and/or diabetes. Antipsychotics are not addictive but stopping these medications without your doctor’s guidance can be very dangerous, so you’ll need to work closely with your doctor in all your medication decisions.

 

 

Making A Choice:
What information do YOU want to help you make your decision?

 

Here are some possible questions for discussion. Check of the questions that you need answered in order to make a decision, then bring them to your doctor, psychiatrist, caregiver, caseworker, or other team members to spark conversation.

 

❒Why do you think this is the right medication for me?

❒Who needs to know I’m taking this? (teacher, friends, coach, etc)

❒Will I get in trouble if I don’t take this?

❒What are the expected benefits of this medication in my situation?

❒How will this make me feel?

❒Will it make me tired?

❒What are the specific side effects for the medication you are recommending?

❒Will the side effects go away?

❒How long should I expect to wait to see results?

❒What are the names of some antipsychotic medications?

❒What are the other options I have for medication?

❒What are the other options besides medication that may help me?

❒Why am I taking this medication?

❒What will happen if I stop taking it?

❒How will I know if it’s working?

❒How will I know/who will decide when it’s time to get off this medication?

❒What happens if I’m ready to get off them?

❒How long will I be on this medication? For life?

❒What are the specific short term/long term side effects of this medication?

❒What do I do if I have side effects?

❒How might this affect my school, life, family, friends?

❒Who should I tell? Why or why not?

❒What are my rights?

❒Do I get to help decide?

❒How quickly does weight gain happen? Is there anything I can do to maintain my weight?

❒Do I need blood work? What other kinds of medical tests do I need before during and after treatment?

❒What is Tardive Dyskinesia? Will I get it?

❒Who will find out I’ve taken this medication? Are there potential risks to getting a job, or joining the military if I take this medication?

❒How does this help me reach my personal goals?  

What other questions do you have?

❒___________________________________________________

❒___________________________________________________

 

 

 

Making A Choice:
What Are Your Rights?

 

Here is an excerpt from Maine’s Youth Bill of Rights, specific to Mental Health:

•You have the right to have an informed choice in the types of physical, dental and mental health care you receive.

•You have the right to have a choice and options when a treatment provider is being assigned to them.

•You have the right to see and understand your treatment plans, be informed about and have a say in treatment decisions being made.

•You have a right to be informed about medications, medication options and to have a voice in decisions about prescription of medication.

•You have a right to not be overmedicated, to not be punished for refusal to take medications, and to be made aware of the possible risks that come from refusing to take medication.

•You should be able to have visitation with people that are important to you while receiving treatment.

•You should be able to receive care and services that are fair, respectful, safe, confidential and free from discrimination.

•You have a right to access to your medical records.

If you feel your rights have  been violated, you should speak up to your caseworker and say that your rights have been violated, and tell them which one.

If you are still having trouble, you can speak to your caseworker’s supervisor, your guardian ad litem or a trusted adult. Be specific and provide examples.

If you don’t have success there, you can contact the ombudsman’s office. An ombudsman (pronounced om-budz-man) helps people when they have concerns about DHHS’s involvement in families’ lives. You have the right to call the ombudsman if you have a concern. The ombudsman will try to get more information, notify DHHS of problems and work with people to help fix the problems. Call (866)621-0758 or (207)623-1868. http://mainechildrensalliance.org/am/publish/ombudsman/shtml

 

 

 

Making A Choice:
What Are Your Personal Goals?

 

 

Sometimes it is helpful to think about your life goals and determine how this decision might negatively or positively affect your ability to achieve these goals. You can use this worksheet to write your goals.

 

 

In the next three months, my goals are:

 

_______________________________________________________________________________________________

 

 

In the next one or two years, my goals are:

 

_______________________________________________________________________________________________

 

 

If I could look into a crystal ball and see myself 5 years from now, what do I hope for?

 

_______________________________________________________________________________________________

 

 

 

Making A Choice:
What Are The Risks and Benefits?

 

 

You can use this worksheet to organize your thoughts around pros and cons of taking medication. Make sure you think about how they might help you or create challenges for you in reaching YOUR goals. You can share your concerns and hopes for this medication with your support people in family team meetings.

You can list the pros and cons here:

         Pros/Benefits:                                        Cons/Risks:

 

 

 

 

 

Making A Choice:
Who Is Your Team?

You are not alone in this decision—you have support. You can list the people you can talk to to help you make this decision here: