ADVOCATING FOR CHILDREN AND YOUTH IN RESIDENTIAL
ADVOCATING FOR CHILDREN AND YOUTH IN RESIDENTIAL TREATMENT CENTERS Participant Training Manual Advocating for Children and Youth in Residential Treatment Centers Participant Training Manual Table of Contents List of Residential Treatment Centers in Texas in 2010 Researching Residential Treatment Centers in Texas Table of Contents for Minimum Standards for General Residential Operations and RTCs Fact Sheet: Children in Residential Treatment Centers Top 10 Residential Treatment Center Deficiencies Checklist: Gathering Information from the Residential Treatment Center Quick Reference to Psychotropic Medication Psychotropic Medication Utilization Parameters for Foster Children Medicaid Managed Care for Foster Children: A Summary of CPPP Report Residential Treatment for Children and Youth Treatment Plans for Mental Health Sample Treatment Plan #1 Sample Treatment Plan #2 Sample Treatment Plan #3 Sample Treatment Plan #4 Developmental, Mental Health/Behavioral and Academic Screens Advocacy Questions Tree for Provider Advocating for Children with Emotional Problems Checklist: Advocating for a child/youth placed in a RTC Checklist: Advocating for Special Needs Tips for Providing Experiential Life Skills Training in RTCs Resources to Aid Caregivers in Providing Experiential Life Skills Training to Foster Youth A Tip Sheet for Effective Educational Advocacy A Judicial Checklist for Educational Needs Tips for Child Advocates Advocating for Your Child: 25 Tips for Parents Quick Reference Grid on Information Sharing 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 A Child Is Born A Child Is Born A Child is Born A Fresh Start Treatment Center A New Day Foundation Autistic Treatment Center Autistic Treatment Center, Inc. AVALON CENTER INC Azleway Boys Ranch Bayes Achievement Center Brookhaven Youth Ranch Canyon Lakes RTC Carter's Kids Center for Success and Independence Children's Hope Residential Services, Inc. Daystar Residential Inc. DePelchin Children's Center-Richmond Depelchin Childrens Center Devereux-Houston Devereux-Victoria East Texas Open Door Embracing Destiny Foundation EVERYDAY LIFE INC Five Oaks Achievement Center Good Shepherd Guardian Angels Habilitative Homes Inc Have Haven Inc Hearts With Hope Foundation Hector Garza Helping Hand Home for Children High Frontier Hill Country Youth Ranch HMIH CEDAR CREST, LLC Hold My Hand Houston Serenity Place Inc. Houston Wee Care Shelter Inc Residential Treatment Centers Alvin Alvin Liverpool Houston San Antonio Dallas EDDY TYLER HUNTSVILLE West Lubbock Houston Levelland MANVEL Richmond Houston League City VICTORIA MARSHALL Spring Bryan New Ulm TOMBALL Houston San Antonio Houston Spring San Antonio AUSTIN Fort Davis Ingram BELTON Houston Houston Spring 16111 Nacogdoches Road 10503 Metric Drive 480 HWY 7 15892 CR 26 60 LOWRY LANE 5467 Rogers Hill Rd 2402 Canyon Lakes DR 3722 Pinemont Drive 1313 West Washington Ave 3926 BAHLER 710 South 7th St 123 Shepherd 1150 Devereux Drive 120 David Wade 411& 413 West Burleson 17803 Wood Bark Rd 6955 Broach Road 7674 Pechacek Road 23538 COONS ROAD 9530 West Montgomery 9019 Old Sky Harbor Road 14054 Ambrose 17718 August Meadows Ln. 620 East Afton Oaks 3804 AVENUE B 1173 High Frontier Rd. 3522 Junction Highway 3500 S. IH-35 7722 Glen Vista 6509 Morrow 28915 S Plum Creek City 2403 FM 2917 7415 Live Oak Circle 6911 CR 171 7809 Winship Address HARRIS HOCKLEY BRAZORIA FORT BEND HARRIS GALVESTON VICTORIA HARRISON HARRIS BRAZOS AUSTIN HARRIS HARRIS BEXAR HARRIS HARRIS BEXAR TRAVIS JEFF DAVIS KERR BELL HARRIS HARRIS HARRIS BEXAR DALLAS FALLS SMITH WALKER MCLENNAN LUBBOCK BRAZORIA BRAZORIA BRAZORIA HARRIS County 77018 79336 77578 77469 77007 77573 77905 75670 77379 77808 78950 77377 77088 78242 77045 77379 78232 78751 79734 78025 76513 77061 77091 77386 78247 75243 76524 75707 77340 76691 79415 77511 77511 77577 77028 Zip 281-581-2475 281-393-1054 281-581-2704 713-635-1081 281-257-1218 210-590-2107 972-644-2076 254-859-5990 903-566-6827 936-291-3391 254-829-1920 806-762-5782 281-239-6999 713-426-4545 806-897-9735 281-489-0317 281-342-4906 713-861-8136 281-335-1000 361-575-8271 903-935-2099 281-370-6727 979-589-1885 979-992-3791 281-374-0777 281-447-1812 210-623-5419 713-413-9490 281-376-0320 210-568-8600 512-459-3353 432-364-2241 830-367-2131 254-939-2100 713-645-0042 713-691-5572 281-363-4020 Phone 31 15 13 13 13 14 31 32 74 59 71 40 36 44 20 141 20 44 44 85 28 13 44 40 40 24 19 13 14 123 41 84 50 72 13 71 16 Capacity 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 Independence Farm Juliette Fowler Homes Inc KCI Servants Heart Krause Children's Residential L'Amor Village Laurel Ridge Treatment Center Mary Ruth Meridell Achievement Center Minolas Place of Texas INC Minolas Place of Texas INC Nacogdoches Boy's Ranch Nelson Childrens Residential Treatment New Encounters Residential Treatment New Hope Youth Center New Horizons Audrey Grace House New Horizons Ranch New Life Childrens Treatment Center Pegasus Schools, Inc. Positive Steps Inc Renewed Strength Inc Roy Maas Youth Alternatives Meadows San Marcos Treatment Center Shamar Hope Haven Sheltering Harbour Shiloh Treatment Center Shoreline Inc Sinclair Children's Center Southwest Key Program INC Texas Adolescent Treatment Center Texas NeuroRehab Center The Burke Foundation-Pathfinders The Settlement Club Home UT Harris County Psychiatric Center Thompson's Residential Treatment Center Totally Fit Ministries Unity Children's Home Whispering Hills Achievement Center Willow Bend Center Youth and Family Enrichment Centers Inc CORSICANA Dallas San Antonio KATY HOUSTON San Antonio Missouri City Liberty Hill Spring Tomball NACOGDOCHES DENTON CORSICANA Richmond Goldthwaite Canyon Lake Lockhart Houston Houston Boerne San Marcos Houston Spring Manvel Taft WOODVILLE HOUSTON San Antonio Austin Driftwood Austin Houston Crosby Spring Flatonia Tyler TYLER 2715 LIBERTY DRIVE 1220 Abrams Rd 4040 High Ridge Circle 25752 Kingsland Blvd 16540 KUYKENDAHL ROAD 17720 Corporate Woods Dr 16711 Quail View Court 12550 West Hwy. 29 17940 Country Walk 30715 Quinn Rd. 7245 FM 1275 4601 INTERSTATE 35 NORTH 4121 FM ROAD 637 4111 Brandt Rd 850 F M 574 W 650 Scarborough 896 Robin Ranch Rd. 2701 Rosedale 110 Hambrick 121 Old San Antonio Road 120 Bert Brown Road 2719 Truxillo St 17803 W Strack DR 3926 Bahler 1220 Gregory ST 207 NELLIUS STREET 7900 MESA 8550 Huebner 1106 West Dittmar 20800 FM 150 W 1600 Payton Gin Rd 2800 South MacGregor Way 10510 Crosby Lynchburg 2111 River Valley 4110 FM 609 2902 Highway 31 East 14023 Hwy 155 S HARRIS HARRIS FAYETTE SMITH SMITH MILLS COMAL CALDWELL HARRIS HARRIS KENDALL HAYS HARRIS HARRIS BRAZORIA SAN PATRICIO TYLER HARRIS BEXAR TRAVIS HAYS TRAVIS HARRIS NAVARRO DALLAS BEXAR FORT BEND HARRIS BEXAR FORT BEND WILLIAMSON HARRIS HARRIS NACOGDOCHES DENTON NAVARRO FORT BEND 77532 77373 78941 75702 75711 76844 78133 78644 77004 77060 78006 78666 77004 77379 77578 78390 75979 77028 78240 78745 78619 78758 77021 75110 75214 78229 77494 77068 78259 77489 78642 77379 77375 75965 76207 75109 77469 903-874-2377 214-827-0813 210-212-2500 281-392-7505 281-586-9708 210-491-9400 281-416-7822 512-528-2100 281-251-7696 281-290-8146 936-569-0293 940-484-8232 903-874-1577 281-344-8050 325-437-1852 325-938-5518 830-964-4390 512-376-2101 713-522-0559 281-448-7550 830-816-2425 512-396-8500 713-942-8822 281-251-8686 281-489-1290 361-643-6643 409-283-6800 713-635-8505 210-568-8500 512-444-4835 512-858-4258 512-836-2150 713-741-5000 903-883-5437 281-426-5098 281-355-0716 361-865-3083 903-596-8900 903-534-0414 13 28 36 65 42 62 13 134 13 21 26 65 14 16 14 100 60 175 35 13 48 265 22 65 43 36 35 54 145 36 21 35 20 16 18 48 20 52 54 Researching Residential Treatment Centers in Texas On-line information available: The first step is to use your internet search engine (such as “Google”) to type in the name of the RTC and find out what you can discover from their own website. Texas Department of Family and Protective Services: The second step is to visit the DFPS website to view their record. Go to: www.dfps.state.tx.us On the left sidebar, select “Child Care Licensing” On the left sidebar, select “Search Texas Child Care” On the full screen, scroll down and select “Search for a Residential (24 hours) Operation” On the pull down menu by “Operation Type”, select “Residential Treatment Center” On the pull down menu for “Issuance Type“, select “full permit” Now you can search by Name (type in name of the RTC...see your list!), City, County or a combination of those fields Referencing Minimum Standards for Residential Treatment Centers: If you have a particular issue or question, you can refer to the DFPS Minimum Standards for RTCs. Go to: www.dfps.state.tx.us On the left sidebar, select “Child Care Licensing” On the left sidebar, select “Standards and Regulations” Scroll down until you see “Minimum Standards for Residential, 24-hour Care Operations and Child-Placing Agencies” Select “Chapter 748, Minimum Standard Rules for General Residential Operations and Residential Treatment Centers” A Table of Contents is included in your handouts for quick reference Obtaining information from the RTC: Finally, since every RTC is different in type, quality and practices, you will need to gather as much information as you can on your first visit to the RTC. Licensing Division Texas Department of Family and Protective Services MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS AND RESIDENTIAL TREATMENT CENTERS Stock Code XXXX-0000 January 2007 Minimum Standards for General Residential Operations And Residential Treatment Centers Page v Minimum Standards for General Residential Operations and Residential Treatment Centers Introduction ........................................................................................................................................ ix Minimum Standards ............................................................................................................... ix General Residential Operations and Residential Treatment Centers .................................................1 Subchapter A, Purpose and Scope...............................................................................................1 Subchapter B, Definitions and Services........................................................................................3 Division 1, Definitions..............................................................................................................3 Division 2, Services.................................................................................................................8 Subchapter C, Organization and Administration .........................................................................13 Division 1, Permit Holder Responsibilities.............................................................................13 Division 2, Governing Body...................................................................................................16 Division 3, General Fiscal Requirements ..............................................................................17 Division 4, Required Postings ...............................................................................................17 Division 5, Policies and Procedures ......................................................................................19 Subchapter D, Reports and Record Keeping..............................................................................25 Division 1, Reporting Serious Incidents and Other Occurrences ..........................................25 Division 2, Operation Records ..............................................................................................32 Division 3, Personnel Records ..............................................................................................32 Division 4, Child Records ......................................................................................................34 Division 5, Record Retention.................................................................................................35 Subchapter E, Personnel ............................................................................................................37 Division 1, General Requirements ........................................................................................37 Division 2, Child-Care Administrator .....................................................................................39 Division 3, Professional Level Service Providers ..................................................................41 Division 4, Treatment Director...............................................................................................46 Division 5, Caregivers ...........................................................................................................48 Division 6, Contract Staff and Volunteers .............................................................................49 Subchapter F, Training and Professional Development..............................................................53 Division 1, Definitions............................................................................................................53 Division 2, Orientation ...........................................................................................................54 Division 3, Pre-Service Experience and Training ..................................................................54 Division 4, General Pre-Service Training ..............................................................................57 Division 5, Pre-Service Training Regarding Emergency Behavior Intervention ....................58 Division 6, Annual Training ...................................................................................................60 Division 7, First-Aid and CPR Certification............................................................................65 Subchapter G, Child/Caregiver Ratios ........................................................................................67 Subchapter H, Child Rights.........................................................................................................73 Texas Department of Family and Protective Services January 2007 Page vi Minimum Standards for General Residential Operations And Residential Treatment Centers Subchapter I, Admission, Service Planning, and Discharge .......................................................81 Division 1, Admission ............................................................................................................81 Division 2, Emergency Admission .........................................................................................90 Division 3, Educational Services ...........................................................................................92 Division 4, Service Plans.......................................................................................................93 Division 5, Service Plan Reviews and Updates ..................................................................101 Division 6, Discharge and Transfer Planning ......................................................................103 Division 7, Release of Child ................................................................................................106 Subchapter J, Child Care ..........................................................................................................107 Division 1, Dental Care .......................................................................................................107 Division 2, Medical Care .....................................................................................................108 Division 3, Communicable Diseases ...................................................................................112 Division 4, Protective Devices .............................................................................................114 Division 5, Supportive Devices............................................................................................115 Division 6, Tobacco Use .....................................................................................................116 Division 7, Nutrition and Hydration ......................................................................................116 Division 8, Additional Requirements for Infant Care ...........................................................126 Division 9, Additional Requirements for Toddler Care ........................................................130 Division 10, Additional Requirements for Pregnant Children ..............................................132 Subchapter K, Operations That Provide Care for Children and Adults .....................................135 Division 1, Scope ................................................................................................................135 Division 2, General Requirements ......................................................................................135 Subchapter L, Medication .........................................................................................................139 Division 1, Administration of Medication .............................................................................139 Division 2, Self-Administration of Medication ......................................................................141 Division 3, Medication Storage and Destruction .................................................................142 Division 4, Medication Records ...........................................................................................143 Division 5, Medication and Label Errors..............................................................................144 Division 6, Side Effects and Adverse Reactions to Medication ...........................................145 Division 7, Use of Psychotropic Medication ........................................................................146 Subchapter M, Discipline and Punishment ...............................................................................149 Subchapter N, Emergency Behavior Intervention .....................................................................153 Division 1, Definitions..........................................................................................................153 Division 2, Types of Emergency Behavior Intervention That May Be Administered ...........155 Division 3, Orders................................................................................................................158 Division 4, Responsibilities During Administration of Any Type of Emergency Behavior Intervention........................................................................................................161 Division 5, Additional Responsibilities During Administration of a Personal Restraint ........163 Division 6, Additional Responsibilities During Administration of Seclusion .........................165 January 2007 Texas Department of Family and Protective Services Minimum Standards for General Residential Operations And Residential Treatment Centers Page vii Division 7, Additional Responsibilities During Administration of a Mechanical Restraint ....166 Division 8, Successive Use and Combinations of Emergency Behavior Intervention .........167 Division 9, Time Restrictions for Emergency Behavior Intervention....................................170 Division 10, General Caregiver Responsibilities, Including Documentation, After the Administration of Emergency Behavior Intervention..........................................173 Division 11, Triggered Reviews...........................................................................................176 Division 12, Overall Operation Evaluation...........................................................................178 Subchapter O, Safety and Emergency Practices......................................................................181 Division 1, Sanitation and Health Practices ........................................................................181 Division 2, Natural Gas and Liquefied Petroleum ...............................................................185 Division 3, Fire Safety Practices .........................................................................................186 Division 4, Heating Devices ................................................................................................190 Division 5, Carbon Monoxide Safety Practices ...................................................................191 Division 6, Emergency Evacuation and Relocation.............................................................192 Division 7, First-Aid Kits ......................................................................................................195 Subchapter P, Physical Site......................................................................................................197 Division 1, Grounds and General Requirements.................................................................197 Division 2, Interior Space ....................................................................................................199 Division 3, Toilet and Bath Facilities ...................................................................................204 Division 4, Poisons..............................................................................................................207 Division 5, Food Preparation, Storage, and Equipment ......................................................207 Division 6, Play Equipment and Safety Requirements ........................................................212 Division 7, Playground Use Zones ......................................................................................215 Division 8, Protective Surfacing ..........................................................................................217 Division 9, Swimming Pools, Wading/Splashing Pools, and Hot Tubs................................218 Subchapter Q, Recreation Activities .........................................................................................221 Division 1, General Requirements ......................................................................................221 Division 2, Swimming Activities ...........................................................................................225 Division 3, Watercraft Activities...........................................................................................228 Division 4, Wilderness Hiking and Camping Excursions .....................................................229 Division 5, Trampoline Use .................................................................................................237 Division 6, Weapons, Firearms, Explosive Materials, and Projectiles.................................238 Subchapter R, Transportation ...................................................................................................241 Division 1, General Requirements ......................................................................................241 Division 2, Safety Restraints ...............................................................................................244 Division 3, Vehicle and Vehicle Maintenance .....................................................................246 Division 4, Transportation Records .....................................................................................246 Subchapter S, Additional Requirements for Operations That Provide Emergency Care Services.......................................................................................247 Texas Department of Family and Protective Services January 2007 Page viii Minimum Standards for General Residential Operations And Residential Treatment Centers Division 1, Service Management.........................................................................................247 Division 2, Admission Assessment .....................................................................................249 Division 3, Respite Child-Care Services .............................................................................251 Subchapter T, Additional Requirements for Operations That Provide an Assessment Services Program ...............................................................................253 Division 1, Regulation .........................................................................................................253 Division 2, Admission ..........................................................................................................253 Division 3, Assessment Plan ...............................................................................................254 Division 4, Assessment Report ...........................................................................................255 Subchapter U, Additional Requirements for Operations That Provide Therapeutic Camp Services...................................................................................................................257 Division 1, Definitions..........................................................................................................257 Division 2, Activities Requiring Spotting or Belaying ...........................................................258 Division 3, Primitive Camping Excursions ...........................................................................259 Index ...............................................................................................................................................263 January 2007 Texas Department of Family and Protective Services Fact Sheet: Children in Residential Treatment Centers I. Tens of thousands of children with mental health needs are being placed in expensive, inappropriate and often dangerous institutions. The number of children placed in residential treatment centers (or RTCs)[1] is growing exponentially.[2] These modern-day orphanages now house more than 50,000 children nationwide.[3] Children are packed off to RTCs, often sent by officials they have never met, who have probably never spoken to their parents, teachers or social workers.[4] Once placed, these kids may have no meaningful contact with their families or friends for up to two years.[5] And, despite many documented cases of neglect and physical and sexual abuse, monitoring is inadequate to ensure that children are safe, healthy and receiving proper services in RTCs.[6] By funneling children with mental illnesses into the RTC system, states fail—at enormous cost—to provide more effective community-based mental health services.[7] A. RTC placements are often inappropriate. RTCs are among the most restrictive mental health services and, as such, should be reserved for children whose dangerous behavior cannot be controlled except in a secure setting.[8] Too often, however, childserving bureaucracies hastily place children in RTCs because they have not made more appropriate community-based services available.[9] Parents who are desperate to meet their kids’ needs often turn to RTCs because they lack viable alternatives.[10] To make placement decisions, families in crisis and overburdened social workers rely on the institutions’ glossy flyers and professional websites with testimonials of saved children.[11] But all RTCs are not alike.[12] Local, state and national exposés and litigation “regarding the quality of care in residential treatment centers have shown that some programs promise high-quality treatment but deliver low-quality custodial care.”[13] As a result, parents and state officials play a dangerous game of Russian roulette as they decide where to place children, because little public information is available about the RTCs, which are under-regulated and under-supervised. To make it worse, far too many children are placed at great distance from their homes. For example, most District of Columbia children in RTCs are placed outside the District—many as far away as Utah and Minnesota.[14] Many families, especially those with limited means, find it impossible to have any meaningful visitation with their children. B. Evidence is limited on the effectiveness of RTCs. Children frequently arrive at RTCs traumatized by the process that delivered them there. They are often forcibly removed from their homes in the middle of the night by “escort companies.”[15] Other times, children are placed in RTCs not by their parents or doctors, but by overburdened child-serving state agencies, who know little about the children’s individual needs.[16] Even more appalling, many children’s conditions do not improve at all while at the RTC.[17] In fact, there is little evidence that placing children in RTCs has any positive impact at all on their mental health state[18] and any gains made during a stay in an RTC quickly disappear upon discharge, creating a cycle where children return again and again to RTCs.[19] There are many reasons why RTCs fail to deliver the results they promise, but most center on the type of services provided, the environment they are provided in and the lack of family involvement. First, the reality of what occurs within an RTC is often quite different from the highly individualized, highly structured programs that are advertised. The RTCs often provide less intense services and the staff are often under-trained.[20] Children spend much of their day with staff who are not much more qualified than the average parent and they spend less time face-to-face with psychiatrists than they would if they were being served in appropriate community settings.[21] The environment is also problematic because children in RTCs enter a situation where their only peers are other troubled children—a major risk factor for later behavioral problems.[22] Research has demonstrated that some children learn antisocial or bizarre behavior from intensive exposure to other disturbed children.[23] Children are usually far from home in RTCs, often out-of-state.[24] Removed from their families and natural support systems, they are unable to draw upon the strengths of their communities and their communities are unable to contribute to their treatment. Few children thrive when they are hundreds or thousands of miles from their parents, friends, grandparents and teachers. Few can flourish without the guidance of consistent parenting. Yet, we expect that our most vulnerable and troubled youth will miraculously turn around in just such a situation. Instead, this isolation further reduces the efficacy of treatment and increases its cost.[25] The fact that children and their families are far from one another creates a host of problems. For one, it makes family therapy difficult or impossible. As a result, when children leave the RTC, they return to an environment that has not changed. Also, because the RTC environment is inherently artificial—children are not asked to negotiate the obstacles that occur within their family setting or deal with the difficulties that trigger their behaviors in their neighborhoods or schools—the child does not gain new skills to better negotiate life outside of an institution. As a result, neither the children nor their parents learn better ways to overcome the obstacles that led to the RTC placement. Without family involvement, successes are limited.[26] Among the rare children who are able to overcome these obstacles, few can sustain the gains they have made. In one study, nearly 50% of children were readmitted to an RTC, and 75% were either renstitutionalized or arrested.[27] C. Children suffer because there is no watchdog. The RTC industry is largely unregulated.[28] RTCs need only report major unusual incidents (or MUIs), but the interpretation of what constitutes an MUI and the reporting requirements vary widely.[29] Some RTCs fail to report MUIs at all—with little consequence.[30] Vulnerable kids are placed far from home where parents, social workers, or the state can offer little oversight or protection. Worse, many of the facilities limit children’s ability to have contact with their parents for extended periods, further restricting the parents’ ability to monitor the facilities.[31] D. Children are abused in RTCs. Children placed in RTCs have been sexually and physically abused, restrained for hours, over-medicated and subject to militaristic punishments; some have died.[32] The following are just a few documented examples of tragic occurrences at RTCs: • • • • • • Medication is often used (and overused) to control behavior.[33] Children have been permanently disfigured because of over-medication.[34] In some programs, the children’s shoes are confiscated to keep them from running away.[35] There have been reports of behavioral ‘therapies’ being misused. As one author noted, “Such therapies do little more than systematically punish children, all under the guise of treatment.”[36] Sexual abuse by staff members and other residents is all too frequent.[37] In one case, a 13-year old girl performed sexual favors for staff members in return for snacks and carryout food.[38] At one RTC, four boys were accused of trying to sodomize another with a cucumber.[39] At another, a 19-year-old woman was charged with sodomizing a 14-year-old girl.[40] Physical abuse is also too frequent an occurrence. For example, a 13-year-old boy was forced against a wall and slammed to the floor by employees of an RTC.[41] Children are often restrained—sometimes for hours on end. The overuse of restraint has resulted in child deaths.[42] E. Tragic outcomes at great public expense. RTCs have grown to a billion-dollar, largely private industry.[43] Residential treatment care is exorbitantly expensive—costing up to $700 per child per day.[44] Annual costs can exceed $120,000.[45] Most of the time, the public foots the bill for these services.[46] In fact, nearly one fourth of the national outlay on child mental health is spent on care in these settings.[47] II. Other Interventions Work Better for Less Home- and community-based services are much more therapeutically effective than institutional services, and are also markedly more cost-efficient. As the Surgeon General reported, “the most convincing evidence of effectiveness is for home-based services and therapeutic foster care” and not for RTCs.[48] A comprehensive system of care would dramatically reduce the number of children in RTCs.[49] Community-based alternatives produce better short- and long-term results and are less disruptive to children and families. These alternatives provide intensive mental health treatment, mobilize community resources and help children and their families develop effective coping mechanisms. Some models endeavor to “wrap services around” the child, while others emphasize multi-systemic therapy and crisis intervention. Randomized clinical trials found greater declines in delinquency and behavioral problems, greater increases in functioning, greater stability in housing placements and greater likelihood of permanent placement.[50] In Milwaukee, a wraparound project that has served over 700 youth involved in juvenile justice has shown similar promise; use of residential treatment has declined 60%, use of psychiatric hospitalization has declined 80%, and average overall care costs for target youth have dropped by one third.[51] Notes [1] According to the Surgeon General, a RTC is a “licensed 24-hour facility (although not licensed as a hospital), which offers mental health treatment.” U.S. Department of Health and Human Services. 1999. Mental Health: A Report of the Surgeon General. Washington, DC: Author. Available at: http://www.surgeongeneral.gov/library/mentalhealth/chapter3/sec7.html#treatment. [2] In 1982, when Jane Knitzer wrote the seminal book, Unclaimed Children, the growth in the RTC industry was only beginning. Ms. Knitzer wrote that: “In contrast to the minimal efforts to create nonresidential services, 18 of the 44 states responding to our survey were working to increase residential care.” Knitzer, J., Unclaimed Children: The Failure of Public Responsibility to Children and Adolescents in Need of Mental Health Care, Children’s Defense Fund, 1982, at 45. By 1986, the number of children in RTCs had grown to 25,334, an increase of more than 30% over a three-year period. Rivera, V.R. & Kutash, K. (1994), Components of a System of Care. What Does the Research Say?, Residential Services: Psychiatric Hospitals and Residential Treatment Centers, at 8, Tampa , FL: University of South Florida, Florida Mental Health Institute: The Research and Training Center for Children’s Mental Health. This growth in continuing. See infra, at note 3. [3] Latest Findings in Children’s Mental Health, Nearly 66,000 Youth Live in U.S, Mental Health Programs, Vo1. 2, No. 1 (Summer 2003). In 1997, the year in which the most recent data was available, more than 42,000 children were living in RTCs. Given the expansion of children living in RTCs, see supra note 2, this figure is likely well over 50,000 now. [4] Reports to staff attorneys at the Bazelon Center for Mental Health Law. For example, in Washington, D.C., children are certified to go to RTCs by a “Multi-Agency Planning Team” process (or MAPT process). The MAPT meetings often do not include the voices of the people who know the child and family best. [5] Ohio Rights Service Review of Fifteen Children’s Mental Health Facilities (October 2004) (on file with the Bazelon Center) [6] See infra at sections I(C) and I(D). [7] This development of long-term residential care occurred at the expense of community-based alternatives. Jane Knitzer, as far back as 1982, noted that: “In general, funds were used to develop longterm residential care, with few efforts to support or create emergency shelters, respite care programs, or specialized foster care for disturbed children and adolescents.” Unclaimed Children, supra note 2, at 46. Further, the Surgeon General noted that one of the primary reasons that RTCs are considered to be justified is because community-based alternatives are lacking. See Mental Health: A Report of the Surgeon General, supra note 1. [8] Duchnowski, A.J., Hall, K. S., Kutash, K, and Friedman, R. (1998) The Alternatives to Residential Treatment Study, in Outcomes for Child and Youth with Behavioral and Emotional Disorders and Their Families. See also Mental Health: A Report of the Surgeon General, supra note 1. [9] Mental Health: A Report of the Surgeon General, supra note 1, (“Concerns about residential care primarily relate to criteria for admission . . . .”). [10] Lou Kilzer, Desperate Measures, Rocky Mountain News, July 2, 1999, available at: http://www.denver-rmn.com/desperate/site-desperate/front-pg.htm. [11] Id. [12] Mental Health: A Report of the Surgeon General, supra note 1, (“Settings range from structured ones, resembling psychiatric hospitals, to those that are more like group homes or halfway houses.”); Rivera, V.R. & Kutash, K. (1994), Components of a System of Care. What Does the Research Say?, Tampa , FL: University of South Florida, Florida Mental Health Institute: The Research and Training Center for Children’s Mental Health. [13] Jane Knitzer noted this fact in 1982 in Unclaimed Children, supra note 2, at 46. The calls for reform have only increased as the population of children served in RTCs has grown. See infra at note 29 and accompanying text. [14] Scott Higham and Sewell Chan, District Reexamines Out of Town Centers, The Washington Post, July 16, 2003, available at: http://www.washingtonpost.com/ac2/wpdyn?pagename=article&contentId=A61386-2003Jul15¬Found=true. See also, D.C. Department of Mental Health Data from 2003 Children in Residential Treatment Centers (on file at the Bazelon Center). [15] Kilzer, supra note 10. [16] Supra, note 4. [17] Mental Health: A Report of the Surgeon General, supra note 1. [18] Burns, B.J., Hoagwood, K. & Maultsby, L.T., Improving Outcomes for Children and Adolescents with Serious Emotional and Behavioral Disorders: Current and Future Directions. (“A dominant observation is that the least evidence of effectiveness exists for residential services, where the vast majority of dollars are spent.”); Chamberlain, P. , Treatment Foster Care, US Department of Justice, Office of Juvenile Justice and Delinquency Prevention, Juvenile Justice Bulletin, December, 1998. [19] Brown, E.C. & Greenbaum, P.E., Reinstitutionalization After Discharge from Residential Mental Health Facilities: Competing Risks Survival Analysis. [20] Kilzer, supra note 10. [21] Client reports to Bazelon Center staff attorneys. [22] Mental Health: A Report of the Surgeon General, supra note 1. [23] Mental Health: A Report of the Surgeon General, supra note 1. [24] See, e.g., supra note 14 and accompanying text. [25] National Council on Crime and Delinquency, Focus Newsletter, July 16, 2002 (“[Residential treatment centers] are usually some distance from the youth’s community, alienating the youth from his or her known environment and adding communication and travel costs to the families and communities.”) [26] Myrth Ogilvie, Transitioning From Residential Treatment: Family Involvement & Helpful Supports, in Focal Point (2001), available at: http://www.rtc.pdx.edu/FPinHTML/FocalPointSP01/pgFPsp01Transitioning.shtml. [27] Supra note 25. [28] Since their inception, RTCs have been under-monitored. As Jane Knitzer noted in Unclaimed Children, supra note 2 at 46: “States have not emphasized continued monitoring of children’s care once they are in residential treatment.” Many RTCs are not accredited at all. Further, the RTCs that are certified are accredited by the Joint Organization on Accreditation of Healthcare Organizations (JCAHO), an independent, nonprofit organization. But as many have pointed out “JCAHO’s standards are geared mainly toward monitoring surgical and pharmacological procedures. And so RTCs, which are more like boarding schools than traditional hospitals, can become accredited under standards that have little to do with the daily programs and activities practiced in them.” Meza-Wilson, A. & Harrison, C., Safe Choices for Troubled Teens: Residential treatment centers for troubled teens are plagued by allegations of abuse and ineffectiveness. But do anguished parents have an alternative?, August 12, 2004, available at: http://www.askquestions.org/articles/teens/. [29] Ohio Rights Service Review, supra note 5. [30] Id. Further, the Bazelon Center has been contacted by federally funded Protection and Advocacy organizations who never or rarely received MUIs from the RTCs serving children within their jurisdiction. [31] Friesen, B.J., Kruzich, J.M., Robinson, A., Jivanjee, P., Pullmann, M. & Bowles, C., Straining the Ties that Bind: Limits on Parent-Child Contact in Out-Of-Home Care, in Focal Point (2001), available at: http://www.rtc.pdx.edu/FPinHTML/FocalPointSP01/pgFPsp01Straining.shtml. [32] See e.g., Scott Higham and Sewell Chan, Poor Care, Abuses Alleged at Riverside, The Washington Post, July 15, 2003, available at: http://www.washingtonpost.com/ac2/wpdyn?pagename=article&contentId=A56180-2003Jul14¬Found=true; Kilzer, supra note 10; Associated Press, Death At Residential Treatment Center Ruled a Homicide, May 16, 2002, available at: http://www.geocities.com/ahobbit.geo/residential_treatment.html; Tim Weiner, Parents Divided Over Jamaica Disciplinary Academy, The New York Times, June 17, 2003; Ohio Rights Service Review, supra note 5; Tanya Eiserer, Death of teen at therapy facility investigated: Richardson 17-year-old died being restrained by staff in Hill Country, Dallas Morning News, October 17, 2002; Jorge Fitz-Gibbon, Leah Rae and Shawn Cohen, Treatment Often Hampered By Bureaucracy, The Journal News, June 23, 2002, available at: http://www.nyjournalnews.com/rtc/rtc062302_01.html. [33] Higham and Chan, supra note 32. [34] Reports to staff attorneys at the Bazelon Center for Mental Health Law. [35] Kilzer, supra note 10. [36] Unclaimed Children, supra note 2, at 46. [37] Kilzer, supra note 10. [38] Higham and Chan, supra note 32. [39] Fitz-Gibbon, Rae and Cohen, supra note 32. [40] Id. [41] Higham and Chan, supra note 32. [42] Associated Press, supra note 32. [43] Fitz-Gibbon, Rae and Cohen, supra note 32. [44] Kilzer, supra note 10. [44] Higham and Chan, supra note 32. [45] Fitz-Gibbon, Rae and Cohen, supra note 32. [46] Id. [47] Mental Health: Report of the Surgeon General, supra note 1. [48] Id. [49] Id. The Surgeon General suggests that RTCs are often utilized because of the under-availability of community-based alternatives. [50] Bruns, E.J., Serving Youths with Emotional and Behavioral Problems in Maryland: Opportunities for the Use of the Wraparound Approach, University of Maryland School of Medicine, Department of Psychiatry, September 17, 2003 (on file at the Bazelon Center). [51] Id. at 2. Source: Judge David L. Bazelon Center for Mental Health Law 1101 15th Street, NW, Suite 1212 Washington, DC 20005 Phone: 202-467-5730 Fax: 202-223-0409 Email: webmasteratbazelon.org Top 10 Residential Treatment Center Deficiencies January 1, 2008 through May 31, 2009 Standard Rule * Description Deficiencies Rank 748.3301(a) Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free 88 1 748.507(1) Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks 65 2 748.685(a)(4) Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being 65 2 748.3391(a) Bathrooms-Must be maintained in good repair & kept clean 50 4 748.2151(a)(8) Medication Record-Must include accurate running count of each prescribed medication 47 5 748.3301(i) Physical Site-Equipment and furniture must be safe for 41 children and must be kept clean and in good repair 6 748.3365(a)(3) Bedding-Must provide each child with a mattress cover 28 or protector or mattress that is waterproof or washable 7 745.625(a)(7) Background checks submitted-every 24 months after first submitted 26 8 25 9 Physical Site-Windows & doors must be in good repair 25 & free of broken glass or hazards 9 Mandatory drug testing-all applicants intended to be 745.4151(c)(4)(A) hired are subject to pre-employment testing, must have results prior to child access 748.3301(c) * Only includes deficiencies where the administrative review was upheld or waived. Source: Texas Department of Family and Protective Services (www.dfps.state.tx.us) Checklist: Gathering Information from the RTC Provide them a copy of the order of appointment for their records Ask for a packet of information on their RTC and how it operates What are the goals of the RTC? What is the capacity of the RTC? (how many beds?, are they full?) What is the staff:child ratio? What are the educational levels of staff? Of the therapists? Is staff turnover likely to occur while the child/youth is at their RTC? How long is the average length of stay for a child/youth placed there? What are the different Levels of Care (LOC) served by the RTC? How often does Youth for Tomorrow (YFT) assess the children and/or youth placed there? Ask for a copy of the organizational chart Ask for a copy of the daily schedule What are the rules regarding who the child can initiate contact with and when? Can they be given a phone card to make long-distance calls? What is the best time for CASA to call the child? What is the best time for CASA to visit the child? Is there a protocol CASA should follow to set the appointment that indicates who the contact person is? How much notice is required in scheduling a visit with the child? What is the visitation policy for parents, siblings, relatives, past caretaker? Would the child be given access to a telephone to join their hearing via conference call? Ask for a copy or an explanation of the behavioral management system (levels, privileges) Ask for a copy of the resident handbook (if there is one) What items can the child have and specifically NOT have? How do they view CASA’s role? What has their previous experience with CASA been like (if they’ve had one)? How do I get copies of: the treatment plan, therapy notes, daily activity notes or like records? Who can I speak to get notified of “staffings” or “treatment team meetings”? How often is progress on the treatment plan assessed? Who do you rely on for diagnosis? Who do I contact if I have concerns? Do you have a process for requesting/obtaining a second opinion? How do you determine a child has met the goals and can be returned to a less restrictive environment? How will the family/previous caretaker be involved in the treatment? What is the medication policy? For example, is a child/youth removed from current meds, re-evaluated and started on a new regime? Or are their medications continued with a gradual change, if needed? Who is the psychiatrist the facility uses? Who is the Director of the RTC? Can I have the names of everyone on the Interdisciplinary Team that will be involved in the child’s care? Can I have a tour? quick reference to psychotropic medication® Developed by John Preston, Psy.D., ABPP To the best of our knowledge recommended doses and side effects listed below are accurate. However, this is meant as a general reference only, and should not serve as a guideline for prescribing of medications. Please check the manufacturer’s product information sheet or the P.D.R. for any changes in dosage schedule or contraindications. (Brand names are registered trademarks.) antidepressantS UsualSelective Action On Daily DosageNeurotransmitters2 Range Sedation ACH1 NE 5-HT DA NAMES Generic Brand imipramine desipramine amitriptyline nortriptyline protriptyline trimipramine doxepin clomipramine maprotiline amoxapine trazodone fluoxetine bupropion-X.L. sertraline paroxetine venlafaxine-X.R. fluvoxamine mirtazapine citalopram escitalopram duloxetine atomoxetine mao inhibitors phenelzine tranylcypromine selegiline Tofranil Norpramin Elavil Aventyl, Pamelor Vivactil Surmontil3 Sinequan, Adapin3 Anafranil Ludiomil Asendin Desyrel Prozac4, Sarafem Wellbutrin-X.L.4 Zoloft Paxil Effexor-X.R.4 Luvox Remeron Celexa Lexapro Cymbalta Strattera 150-300 150-300 150-300 75-125 15-40 100-300 150-300 150-250 150-225 150-400 150-400 20-80 150-400 50-200 20-50 75-350 50-300 15-45 10-60 5-20 20-80 60-120 Nardil Parnate Emsam (patch) mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg 30-90 mg 20-60 mg 6-12 mg mid low high mid mid high high high high mid mid low low low low low low mid low low low low mid low high mid mid mid mid high mid low none none none none low none low mid none none none low ++ +++++ ++ +++ ++++ ++ ++ 0 +++++ +++ 0 0 ++ 0 + ++ 0 +++ 0 0 ++++ +++++ +++ 0 ++++ ++ + ++ +++ +++++ 0 ++ ++++ +++++ 0 +++++ +++++ +++ +++++ +++ +++++ +++++ ++++ 0 0 0 0 0 0 0 0 0 0 0 0 0 ++ 0 0 + 0 0 0 0 0 0 low low low none none none +++ +++ +++ +++ +++ +++ +++ +++ +++ ACH: Anticholinergic Side Effects NE: Norepinephrine, 5-HT: Serotonin, DA: Dopamine (0 = no effect, + = minimal effect, +++ = moderate effect, +++++ = high effect) 3 Uncertain, but likely effects 4 Available in standard formulation and time release (XR, XL or CR). Prozac available in 90mg time released/weekly formulation 1 2 BIPOLAR DISORDER MEDICATIONS NAMES Generic Brand lithium carbonate olanzapine/ fluoxetine carbamazepine oxcarbazepine DailySerum1 Dosage Range Level Eskalith, Lithonate 600-2400 0.6-1.5 Symbyax 6/25-12/50mg4 Tegretol,Equetro 600-1600 Trileptal 1200-2400 2 4-10+ (2) NAMES GenericBrand Dosage divalproex gabapentin lamotrigine topiramate tiagabine Depakote Neurontin Lamictal Topamax Gabitril DailySerum1 Range Level 750-1500 50-100 300-2400 (2) 50-500 (2) 50-300 (3) 4-12 (3) Lithium levels are expressed in mEq/l, carbamazepine and valproic acid levels express in mcg/ml. Serum monitoring may not necessary 3Not yet established 4Available in: 6/25, 6/50, 12/25, and 12/50mg formulations 1 2 anti-obsessional NAMES Generic Brand Dose Range1 clomipramine Anafranil 150-300 fluoxetine Prozac1 20-80 sertraline Zoloft1 50-200 paroxetine Paxil1 20-60 fluvoxamine Luvox1 50-300 citalopram Celexa1 10-60 escitalopram Lexapro1 5-30 1often higher doses are required to control obsessive-compulsive symptoms than the doses generally used to treat depression. © Copyright 2007, John Preston, Psy.D and P.A. Distributors mg mg mg mg mg mg mg psycho-stimulants NAMES Generic Brand methylphenidate methylphenidate methylphenidate methylphenidate methylphenidate dexmethylphenidate dextroamphetamine lisdexamphetamine pemoline d- and l-amphetamine modafinil Note: Adult Doses. 1 2 Daily Dosage1 Ritalin 5-50 Concerta2 18-54 Metadate 5-40 Methylin 10-60 Daytrana (patch)15-30 Focalin 5-40 Dexedrine 5-40 Vyvanse 30-70 Cylert 37.5-112.5 Adderall 5-40 Provigil, Sparlon100-400 Sustained release mg mg mg mg mg mg mg mg mg mg mg antipsychotics NAMES Generic Brand Dosage Range1 Sedation Ortho2 EPS3 low potency chlorpromazine thioridazine clozapine mesoridazine quetiapine high potency molindone perphenazine loxapine trifluoperazine fluphenazine thiothixene haloperidol pimozide risperidone paliperidone olanzapine ziprasidone aripiprazole Thorazine Mellaril Clozaril Serentil Seroquel 50-800 150-800 300-900 50-500 150-600 Moban Trilafon Loxitane Stelazine Prolixin5 Navane Haldol5 Orap Risperdal Invega Zyprexa Geodon Abilify mg mg mg mg mg high high high high mid high high high mid mid 20-225 mg 8-60 mg 50-250 mg 2-40 mg 3-45 mg 10-60 mg 2-40 mg 1-10 mg 4-16 mg 3-12 mg 5-20 mg 60-160 mg 15-30mg low mid low low low low low low low low mid low low mid mid mid mid mid mid low low mid mid low mid low ACH Effects4 ++ + 0 + +/0 ++++ +++++ +++++ +++++ + +++ ++++ +++ ++++ +++++ ++++ +++++ +++++ + + +/0 +/0 +/0 +++ ++ ++ ++ ++ ++ + + + + + ++ + Equivalence5 100 100 50 50 50 mg mg mg mg mg 10 mg 10 mg 10 mg 5 mg 2 mg 5 mg 2 mg 1-2 mg 1-2 mg 1-2mg 1-2 mg 10 mg 2 mg Usual daily oral dosage Orthostatic Hypotension Dizziness and falls 3 Acute: Parkinson’s, dystonias, akathisia. Does not reflect risk for tardive dyskinesia. All neuroleptics may cause tardive dyskinesia, except clozapine. 4 Anticholinergic Side Effects. 5 Dose required to achieve efficacy of 100 mg chlorpromazine. 6 Available in time-release IM format. 1 2 anti-anxiety NAMESSingle Dose Generic Brand Dosage Range benzodiazepines diazepam Valium 2-10 chlordiazepoxide Librium 10-50 prazepam Centrax 5-30 clorazepate Tranxene 3.75-15 clonazepam Klonopin 0.5-2.0 lorazepam Ativan 0.5-2.0 alprazolam Xanax, XR 0.25-2.0 oxazepam Serax 10-30 other antianxiety agents buspirone BuSpar 5-20 gabapentin Neurontin 200-600 hydroxyzine Atarax, Vistaril 10-50 propranolol Inderal 10-80 atenolol Tenormin 25-100 guanfacine Tenex 0.5-3 clonidine Catapres 0.1-0.3 prazosin Minipress 5-20 Doses required to achieve efficacy of 5 mg of diazepam 1 Over the counter Name Daily Dose St. John’s Wort SAM-e3 Omega-34 600-1800 mg 400-1600 mg 1-9 g 1, 2 Treats depression and anxiety May cause signifigant drug-drug interactions 3 Treats depression 4 Treats depression and bipolar disorder 1 2 mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg Equivalence 5 25 10 10 0.25 1 0.5 15 mg mg mg mg mg mg mg mg 1 hypnotics NAMES Single Dose Generic Brand Dosage Range flurazepam temazepam triazolam estazolam quazepam zolpidem zaleplon eszopiclone ramelteon diphenhydramine Dalmane Restoril Halcion ProSom Doral Ambien Sonata Lunesta Rozerem Benadryl common side effects anticholinergic effects (block acetylcholine) • dry mouth • constipation • urinary retention • blurred vision • memory impairment • confusional states extrapyramidal effects (dopamine blockade in basal ganglia) • Parkinson-like effects: rigidity, shuffling gait, tremor, flat affect, lethargy • Dystonias: spasms in neck and other muscle groups • Akathisia: intense, uncomfortable sense of inner restlessness • Tardive dyskinesia: often a persistent movement disorder (lip smacking, writhing movements, jerky movements) Note: The above are common side effects. All medications can produce specific or unique side effects. For a more complete description, please see references listed below references and recommended books Handbook of Clinical Psychopharmacology For Therapists (2008) Preston, O’Neal and Talaga 15-30 mg 15-30 mg 0.25-0.5 mg 1.0-2.0 mg 7.5-15 mg 5-10 mg 5-10 mg 1-3 mg 4-16 mg 25-100 mg Quick Reference • Free Downloads Website: www.PsyD-fx.com Clinical Psychopharmacology Made Ridiculously Simple 5th Edition (2008) Preston and Johnson AF T Psychotropic Medication Utilization Parameters for Foster Children DR Developed by: Texas Department of Family and Protective Services and The University of Texas at Austin College of Pharmacy with review and input provided by: v Federation of Texas Psychiatry v Texas Pediatric Society v Texas Academy of Family Physicians v Texas Medical Association September 2010 Psychotropic Medication Utilization Parameters 2 Table of Contents ◆◆ Introduction and General Principles....................................................................... 3-7 ◆◆ Criteria Indicating Need for Further Review of a Child's Clinical Status......................8 T ◆◆ Members of the Ad Hoc Working Group.....................................................................9 AF ◆◆ References.......................................................................................................... 10-11 ◆◆ Medication Charts............................................................................................. 12-18 DR ◆◆ Glossary...................................................................................................................19 September 2010 Psychotropic Medication Utilization Parameters 3 Psychotropic Medication Utilization Parameters for Foster Children Introduction and General Principles to perform such an assessment. It is recognized that in some situations, it may be in the best interest of the child to prescribe psychotropic medications before a physical exam can actually be performed. In these situations, a thorough health history should be performed to assess for significant medical disorders and past response to medications, and a physical evaluation should be performed as soon as possible. The mental health assessment should be performed by an appropriately qualified mental health professional or appropriate primary care physician with experience in providing mental health care to children. The child’s symptoms and functioning should be assessed across multiple domains, and the assessment should be developmentally appropriate. It is very important that information about the child’s history and current functioning be made available to the treating physician in a timely manner, either through an adult who is well-informed about the child or through a comprehensive medical record. It is critical to meet the individual needs of patients and their families in a culturally competent manner. This indicates a need to address communication issues as well as differences in perspective on issues such as behavior and mental functioning. At present there are no biomarkers to assist with the diagnosis of mental disorders, and imaging (e.g., MRI) and other tests (e.g., EEG) are not generally helpful in making a clinical diagnosis of a mental disorder. gering the child or others; when there is marked disturbance of psychophysiological functioning (such as profound sleep disturbance), or when the child shows marked anxiety, isolation, or withdrawal. Given the unusual stress and change in environmental circumstances associated with being a foster child, counseling or psychotherapy should generally begin before or concurrent with prescription of a psychotropic medication. Patient and caregiver education about the mental disorder, treatment options (non-pharmacological and pharmacological), treatment expectations, and potential side effects should occur before and during the prescription of psychotropic medications. DR AF T T he use of psychotropic medications by children is an issue confronting parents, other caregivers, and health care professionals across the United States. Foster children, in particular, have multiple needs, including those related to emotional or psychological stress. Foster children typically have experienced abusive, neglectful, serial or chaotic care taking environments. Birth family history is often not available. These children often present with a fluidity of different symptoms over time reflective of past traumatic and reactive attachment difficulties that may mimic many overlapping psychiatric disorders. Establishment of rapport is often difficult. These multiple factors serve to complicate diagnosis. Foster children may reside in areas of the state where mental health professionals such as child psychiatrists are not readily available. Similarly, caregivers and health providers may be faced with critical situations that require immediate decisions about the care to be delivered. For these and other reasons, a need exists for treatment guidelines and parameters regarding the appropriate use of psychotropic medications in foster children. Because of the complex issues involved in the lives of foster children, it is important that a comprehensive evaluation be performed before beginning treatment for a mental or behavioral disorder. Except in the case of an emergency, a child should receive a thorough health history, psychosocial assessment, mental status exam, and physical exam before the prescribing of psychotropic medication. Psychological testing may be particularly useful in clarifying a diagnosis and informing appropriate treatment. The physical assessment should be performed by a physician or another healthcare professional qualified The role of non-pharmacological interventions should be considered before beginning a psychotropic medication, except in urgent situations such as suicidal ideation, psychosis, self injurious behavior, physical aggression that is acutely dangerous to others, or severe impulsivity endan- September 2010 It is recognized that many psychotropic medications do not have Food and Drug Administration (FDA) approved labeling for use in children. The FDA has a statutory mandate to determine whether pharmaceutical company sponsored research indicates that a medication is safe and effective for those indications that are listed in the approved product labeling. The FDA assures that information in the approved product labeling is accurate, and limits the manufacturer’s marketing to the information contained in the approved labeling. The FDA does not regulate physician and other health provider practice. In fact, the FDA has stated that it does “not limit the manner in which a practitioner may prescribe an approved drug.” Studies and expert clinical experience often support the use of a medication for an “off-label” use. Physicians should utilize the available evidence, expert opinion, their own clinical experience, and exercise their clinical judgment in prescribing what is best for each individual patient. Psychotropic Medication Utilization Parameters Primary care providers play a valuable role in the care of youth with mental disorders. Not only are they the clinicians most likely to interact with children who are in distress due to an emotional or psychiatric disorder, inadequate numbers of child psychiatrists are available to meet all of the mental health needs of children. Primary care clinicians are in an excellent position to perform screenings of children for potential mental disorders, and they should be able to diagnose and treat relatively straightforward situations such as uncomplicated ADHD, anxiety, or depression. As always, consideration should be given regarding the need for referral for counseling, psychotherapy, or behavioral therapy. • Except in the case of an emergency, informed consent should be obtained from the appropriate party(s) before beginning psychotropic medication. Informed consent to treatment with psychotropic medication entails diagnosis, expected benefits and risks of treatment, including common side effects, discussion of laboratory findings, and uncommon but potentially severe adverse events. Alternative treatments, the risks associated with no treatment, and the overall potential benefit to risk ratio of treatment should be discussed. • The frequency of clinician follow-up with the patient should be appropriate for the severity of the child’s condition and adequate to monitor response to treatment, including: symptoms, behavior, function, and potential medication side effects. • In depressed children and adolescents, the potential for emergent suicidality should be carefully evaluated and monitored. • If the prescribing clinician is not a child psychiatrist, referral to or consultation with a child psychiatrist, or a general psychiatrist with significant experience in treating children, should occur if the child’s clinical status has not experienced meaningful improvement within a timeframe that is appropriate for the child’s clinical response and the medication regimen being used. • Before adding additional psychotropic medications to a regimen, the child should be assessed for adequate medication adherence, accuracy of the diagnosis, the occurrence of comorbid disorders (including substance abuse and general medical disorders), and the influence of psychosocial stressors. AF Primary care providers vary in their training, clinical experience, and confidence to address mental disorders in children. Short courses and intensive skills oriented seminars may be beneficial in assisting primary clinicians in caring for children with mental disorders. Active liaisons with child psychiatrists who are available for phone consultation or referral can be beneficial in assisting primary care clinicians to meet the mental health needs of children. • In making a decision regarding whether to prescribe a psychotropic medication in a specific child, the clinician should carefully consider potential side effects, including those that are uncommon but potentially severe, and evaluate the overall benefit to risk ratio of pharmacotherapy. T Role of Primary Care Providers 4 • During the prescription of psychotropic medication, the presence or absence of medication side effects should be documented in the child’s medical record at each visit. • Appropriate monitoring of indices such as height, weight, blood pressure, or other laboratory findings should be documented. • Monotherapy regimens for a given disorder or specific target symptoms should usually be tried before polypharmacy regimens. DR General principles regarding the use of psychotropic medications in children include: • A DSM-IV psychiatric diagnosis should be made before the prescribing of psychotropic medications. • Clearly defined target symptoms and treatment goals for the use of psychotropic medications should be identified and documented in the medical record at the time of or before beginning treatment with a psychotropic medication. These target symptoms and treatment goals should be assessed at each clinic visit with the child and caregiver. Whenever possible, recognized clinical rating scales (clinician, patient, or caregiver assessed, as appropriate) or other measures should be used to quantify the response of the child’s target symptoms to treatment and the progress made toward treatment goals. • Doses should usually be started low and titrated carefully as needed. • Only one medication should be changed at a time, unless a clinically appropriate reason to do otherwise is documented in the medical record. (Note: starting a new medication and beginning the dose taper of a current medication is considered one medication change). • The use of “prn” or as needed prescriptions is discouraged. If they are used, the situation indicating need for the administration of a prn medication should be clearly indicated as well as the maximum number of prn doses in a day and a week. The frequency of administration should be monitored to assure that these do not become regularly scheduled medications. September 2010 • If a medication is being used in a child for a primary target symptom of aggression associated with a DSM-IV nonpsychotic diagnosis (e.g., conduct disorder, oppositional defiant disorder, intermittent explosive disorder), and the behavior disturbance has been in remission for six months, then serious consideration should be given to slow tapering and discontinuation of the medication. If the medication is continued in this situation, the necessity for continued treatment should be evaluated at a minimum of every six months. • The clinician should clearly document care provided in the child’s medical record, including history, mental status assessment, physical findings (when relevant), impressions, adequate laboratory monitoring specific to the drug(s) prescribed at intervals required specific to the prescribed drug and potential known risks, medication response, presence or absence of side effects, treatment plan, and intended use of prescribed medications. Psychotropic Medication Utilization Parameters choice. Second generation antipsychotics are prone to cause significant weight gain in many children, but the risk for the development of weight gain in youth varies significantly among the 2nd generation agents. In a recent study over approximately 11 weeks, the average weight gain was olanzapine (8.5kg), quetiapine (6.1 kg), risperidone (5.3 kg), and aripiprazole (4.4 kg). Olanzapine and quetiapine also caused significant increases in cholesterol and triglycerides, and risperidone increased triglycerides (Correll 2009). First generation antipsychotics are prone to causing extrapyramidal side effects. In particular, youth are especially susceptible to developing acute dystonic reactions from 1st generation antipsychotics. Similarly, 1st generation antipsychotics pose a higher risk for the development of tardive dyskinesia in chronically treated individuals. If antipsychotics are indicated, the clinician should carefully evaluate the individual needs of the child, actively engage the family in decision-making, evaluate overall benefit to risk ratio, and when indicated, choose the antipsychotic that the clinician thinks will be best tolerated by that child. AF The use of psychotropic medication in young children of preschool ages is a practice that is limited by the lack of evidence available for use of these agents in this age group. The Preschool Psychopharmacology Working Group (PPWG) published guidelines summarizing available evidence for use of psychotropic medications in this age group (Gleason 2007). The PPWG was established in response to the clinical needs of preschoolers being treated with psychopharmacological agents and the absence of systematic practice guidelines for this age group, with its central purpose to attempt to promote an evidence-based, informed, and clinically sound approach when considering medications in preschool-aged children. The working group’s key points and guidelines are similar to the general principles regarding the use of psychotropic medication in children already detailed in this paper. However, the working group’s algorithms put more emphasis on treating preschool-aged children with nonpsychopharmacological interventions (for up to 12 weeks) before starting psychopharmacological treatment, in an effort to be very cautious in introducing psychopharmacological interventions to rapidly developing preschoolers. The working group also emphasizes the need to assess parent functioning and mental health needs, in addition to training parents in evidence-based behavior management, since parent behavior and functioning can have a large impact on behavior and symptoms in preschool-aged children. T Use of Psychotropic Medication in Preschool Age Children 5 Antipsychotic selection Significant controversy exists regarding the use of 2nd generation versus 1st generation antipsychotics. Most of the data supporting no difference in efficacy between these two groups of antipsychotics comes from studies conducted in chronically ill adults with schizophrenia. Most of the controlled studies of the use of antipsychotics to treat behavioral disorders in children have been performed with 2nd generation antipsychotics, with the best evidence for risperidone. The only study comparing a 1st generation antipsychotic versus 2nd generation antipsychotics in youth was conducted in individuals with early onset schizophrenia. The 1st generation agent used in this study was molindone, an infrequently used antipsychotic that is known to be weight neutral or cause weight loss in adults. It is unknown how the results of this study can be extrapolated to the treatment of children with externalizing disorders such as conduct disorder or oppositional defiant disorders – the most common situations in which antipsychotics are prescribed in children. DR The PPWG guidelines emphasize consideration of multiple different factors when deciding on whether to prescribe psychotropic medications to preschool-aged children. Such factors include the assessment and diagnostic methods utilized in evaluating the child for psychiatric symptoms/illness, the current state of knowledge regarding the impact of psychotropic medication use on childhood neurodevelopmental processes, the regulatory and ethical contexts of use of psychotropic medications in small children (including available safety information and FDA status), and the existing evidence base for use of psychotropic medication in preschool aged children. Therapeutic Controversies The publication includes specific guidelines and algorithm schematics developed by the PPWG to help guide treatment decisions for a number of psychiatric disorders that may present in preschoolaged children, including Attention-Deficit Hyperactivity Disorder, Disruptive Behavioral Disorders, Major Depressive Disorder, Bipolar Disorder, Anxiety Disorders, Post-Traumatic Stress Disorder, Obsessive-Compulsive Disorder, Pervasive Developmental Disorders, and Primary Sleep Disorders. Antipsychotics vary with regard to their side effect profiles, and side effects are the primary basis for individual medication September 2010 Depression, Suicidality, and Depression In October 2003, the FDA released a public health advisory alerting health care professionals to reports of suicidality (suicidal ideation and suicide attempts) in clinical trials of antidepressants in pediatric populations. These reports provided the impetus for a FDA meta-analytic review of short-term clinical trials of antidepressants in children and adolescents. These analyses involved review, assessment, and reclassification of over 400 case descriptions. This review ultimately resulted in findings of an increased risk of suicidality during the first few weeks of antidepressant treatment. The FDA responded by issuing a black box warning in October 2004. The black box warning describes an increased risk of suicidality (suicidal behavior and ideation) for ALL antidepressants used in individuals under the age of 18. The incidence of suicidal ideations and behaviors in these pooled analyses was about 4% for those youth receiving antidepressants compared with Psychotropic Medication Utilization Parameters Stimulants and cardiovascular side effects Both stimulants and atomoxetine cause small but statistically significant increases in blood pressure and pulse rate. However, it is unclear whether these changes are clinically significant. Although case reports of sudden death in children taking stimulants have been reported, a causal link has not been proven (Vitello 2008). However, a recent case control study suggests that there may be an association (Gould 2009). It is thought that underlying cardiac disorders such as serious structural abnormalities, cardiomyopathies, serious heart rhythm disturbances, or other serious cardiac problems may place children at increased risk of sudden death when stimulants are administered (FDA approved product labeling for Adderall and Concerta, 2008; Perrin 2008). The clinician should conduct a careful history of the child and the family regarding potential heart problems. A thorough physical exam should also be conducted. If the history and physical provide suspicion of a cardiac problem, then an electrocardiogram should be considered before beginning a stimulant. If the child has a known history of a cardiac problem, then a cardiology consult should be considered before beginning a stimulant (Perrin 2008). effects reported during clinical trials, as well as those discovered during post-marketing evaluation. Many tertiary drug information resources also report information regarding common adverse effects and precautions for use with psychotropic medications. At times, post-marketing evaluation may detect critical adverse effects associated with significant morbidity and mortality. The Food and Drug Administration (FDA) may require manufacturers to revise product labeling to indicate these critical adverse effects. If found to be particularly significant, these effects are demarcated by a black box outlining the information at the very beginning of the product labeling, and have, in turn, been named black box warnings. Black box warnings are the strongest warning required by the FDA. It is important for clinicians to be familiar with all medication adverse effects, including black box warnings, in order to appropriately monitor patients and minimize the risk of their occurrence. DR AF The mortality risk of depression is from suicide. Other major suicide risk factors that should be assessed include: substance abuse, conduct disorder, life stressors (such as legal or disciplinary/school problems), interpersonal losses, family and peer discord, abuse, lack of support, poor interpersonal problem-solving ability, the tendency to respond with hostility or overt aggression to frustration or stress, hopelessness and cognitive distortions. All youth with depression should be monitored carefully for the potential presence of suicidal thoughts or behaviors. This should occur at the time of initial clinical assessment and upon each visit follow-up until depression is no longer present. Assessment of suicidality should include asking questions about ideation and frequency, plans, intention, and potential dangerousness. More frequent visits, combined with follow-up calls as necessary, should be considered along with appropriate review of safety plans. It is noteworthy that in one study, the concomitant use of cognitive behavioral therapy was shown to decrease the incidence of suicidality associated with SSRI use. vacations, this has been suggested as one mechanism to minimize potential effects on growth. It is questionable whether the use of stimulants has any effect on ultimate adult height (Vitello 2008; Swanson 2008). T 2% on placebo. It is important to note that no completed suicides were reported in any of these trials. 6 Stimulants and growth Parents and caregivers are often concerned about the possibility that stimulants may adversely affect growth. This is largely related to the fact that, at least short term, stimulants decrease appetite. Although data from different studies are mixed, results from the Multimodal Treatment of ADHD (MTA) study, indicate that weight loss occurred during the first 3-4 months of treatment, but this was followed be a resumption of weight increase. The rate of growth in height decreased by about 1-3 cm/year over the first 1-3 years of medication treatment. However, it should be noted that these decreases in height were only seen in the youth who were adherent with their stimulant medications. Although both advantages and disadvantages are associated with medication holidays or Distinguishing between Levels of Warnings Associated with Medication Adverse Effects Psychotropic medications have the potential for adverse effects, some that are treatmentlimiting. Some adverse effects are detected prior to marketing, and are included in product labeling provided by the manufacturers. When looking at product labeling, these adverse effects will be listed in the “Warnings and Precautions” section. As well, the “Adverse Reactions” section of the product labeling will outline those adverse September 2010 The FDA has in recent years taken additional measures to try and help patients avoid serious adverse events. New guides called Medication Guides have been developed, and are specific to particular drugs and drug classes. Medication Guides advise patients and caregivers regarding possible adverse effects associated with classes of medications, and include precautions that they or healthcare providers may take while taking/prescribing certain classes of medications. FDA requires that Medication Guides be issued with certain prescribed drugs and biological products when the Agency determines that certain information is necessary to prevent serious adverse effects, that patient decision-making should be informed by information about a known serious side effect with a product, or when patient adherence to directions for the use of a product are essential to its effectiveness. During the drug distribution process, if a Medication Guide has been developed for a certain class of medications, then one must be provided with every new prescription and refill of that medication. Psychotropic Medication Utilization Parameters Copies of the Medication Guides for psychotropic medications can be accessed on the FDA website at: http://www.fda.gov/Drugs/DrugSafety/ ucm085729.htm. Usual Recommended Doses of Common Psychotropic Medications These are intended to serve as a guide for clinicians. The tables are not intended to serve as comprehensive drug information references or a substitute for sound clinical judgment in the care of individual patients, and individual patient circumstances may dictate the need for the use of higher doses in specific patients. In these cases, careful documentation of the rationale for the higher dose should occur, and careful moni- toring and documentation of response to treatment should be observed. Not all medications prescribed by clinicians for psychiatric diagnoses in children and adolescents are included below. However, in general, medications not listed do not have adequate efficacy and safety information available to support a usual maximum dose recommendation. See Medication Charts beginning on page 12. DR AF T The attached medication charts are intended to reflect usual doses and brief medication information of commonly used psy- chotropic medications. The preferred drug list of medications potentially prescribed for foster children is the same as for all other Medicaid recipients. 7 September 2010 Psychotropic Medication Utilization Parameters 8 Criteria Indicating Need for Further Review of a Child’s Clinical Status T he following situations indicate a need for further review of a patient’s case. These parameters do not necessarily indicate that treatment is inappropriate, but they do indicate a need for further review. For a child being prescribed a psychotropic medication, any of the following suggests the need for additional review of a patient’s clinical status: 1. Absence of a thorough assessment of DSM-IV diagnosis in the child’s medical record 2. Five (5) or more psychotropic medications prescribed concomitantly (side effect medications are not included in this count) 3. Prescribing of: T (a) Two (2) or more concomitant antidepressants (if an additional one is used, may be reviewed but will be allowed if reasonable for the indications. (b) Two (2) or more concomitant antipsychotic medications (c) Two (2) or more concomitant stimulant medications1 (d) Three (3) or more concomitant mood stabilizer medications AF NOTE: For the purpose of this document, polypharmacy is defined as the use of two or more medications for the same indication (i.e., specific mental disorder). 1 The prescription of a long-acting stimulant and an immediate release stimulant of the same chemical entity (e.g., methylphenidate) does not constitute concomitant prescribing. 2 When DR switching psychotropics, medication overlap and cross-titration may be utilized before discontinuing the first medication 4. The prescribed psychotropic medication is not consistent with appropriate care for the patient’s diagnosed mental disorder or with documented target symptoms usually associated with a therapeutic response to the medication prescribed. 5. Psychotropic polypharmacy for a given mental disorder is prescribed before utilizing psychotropic monotherapy. 6. The psychotropic medication dose exceeds usual recommended doses. 7. Psychotropic medications are prescribed for children of very young age, including children receiving the following medications with an age of: s Antidepressants: s Antipsychotics: s Psychostimulants: Less than four (4) years of age Less than four (4) years of age Less than three (3) years of age 8. Prescribing by a primary care provider who has not documented previous specialty training for a diagnosis other than the following (unless recommended by a psychiatrist consultant): s s s Attention Deficit Hyperactive Disorder (ADHD) Uncomplicated anxiety disorders Uncomplicated depression September 2010 Psychotropic Medication Utilization Parameters 9 Members of the Ad Hoc Working Group on Psychotropic Medication Guidelines for Foster Children M. Lynn Crismon, Pharm.D., Dean, Doluisio Chair, Behrens Inc. Centennial Professor, College of Pharmacy, University of Texas at Austin, Austin, TX James A. Rogers, MD: Medical Director, Texas Department of Family and Protective Services, Austin, TX. T Peter Jensen, M.D.: President & CEO The REACH Institute Resource for Advancing Children’s Health. New York City, NY. Lynn Lasky Clark: President & CEO, Mental Health America of Texas, Austin, TX. Charles Fischer, MD, Chief Psychiatrist, Child and Adolescent Unit, Austin State Hospital, Austin, TX. AF Carroll W. Hughes, PhD, ABPP, Professor of Psychiatry, UT Southwestern Medical Center, Dallas ,TX. Mark Janes, MD: Medical Director, Burke Center, Lufkin, TX. James C. Martin, MD, VP for Medical Affairs, Christus Santa Rosa Health Center, San Antonio, TX. Octavio N. Martinez, Jr., MD., Executive Director Hogg Foundation for Mental Health, University of Texas at Austin, Austin, TX. Nina Jo Muse, M.D., Child Psychiatrist, Texas Department of State Health Service, and private consultation practice, Austin, TX Sylvia Muzquiz-Drummond, M.D., Medical Director MHMRA of Harris County, Houston, TX. DR Steven Pliszka, M.D., Professor, Vice Chair, and Chief of the Child Psychiatry Division, Department of Psychiatry, University of Texas Health Science Center at San Antonio. San Antonio, TX Manuel Schydlower, MD, Associate Academic Dean for Admission Texas Tech University Health Sciences Center Paul L. Foster School of Medicine at El Paso, El Paso, TX William C. Streusand, MD, Medical Director, Texas Child Study Center, Seton Family of Hospitals, Austin, TX. September 2010 Psychotropic Medication Utilization Parameters 10 References 1. 21 CFR Part 201. Specific Requirements on Content and Format of Labeling for Human Prescription Drugs: Revision of “Pediatric Use” Subsection in the Labeling; Final Rule, Federal Register: December 13, 1994. 2. Advisory Committee on Psychotropic Medications. The use of psychotropic medications for children and youth in the Texas foster care system. Texas Department of Family and Protective Services, September 1, 2004. 3. American Academy of Pediatrics. Clinical practice guideline: Treatment of the school age child with attention deficit/hyperactivity disorder. Pediatrics 2001;108:1033-44. 4. Blair BS, Scahill L, State M, Martin A. Electro-cardiographic changes in children and adolescents treated with Ziprasidone: A Propective Study. J Am Acad Child Adolesc Psychiatry 2005; 44:73-79 T 5. Children and Adolescents’ Psychoactive Medication Workgroup. Psychoactive medication for children and adolescents: Orientation for Parents, Guardians, and Others. Massachusetts Department of Mental Health, Boston, July 2007. http://www.mass.gov/dmh/publications/PsychoactiveBooklet.pdf (accessed May 8, 2009) 6. Crismon ML, Argo T. The Use of Psychotropic Medication for Children in Foster Care. Child Welfare 2009;88:71-100. AF 7. Correll CU, Manu P, Olshanskiy V, et al; Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents; JAMA 2009; 302(16):1765-73. 8. Dopheide JA. Recognizing and treating depression in children and adolescents. Am J Health-Syst Pharm 2006;63:233-43. 9. Eden J, Wheatley B, McNeil B, Sax, H. Knowing what works in health care: A roadmap for the nation. Washington, DC: National Academies Press, 2008; 288 pp. 10. Emslie GJ, Hughes CW, Crismon ML, Lopez M, Pliszka S, Toprac MG, Boemer C. A feasibility study of the childhood depression medication algorithm: the Texas Children’s Medication Algorithm Project (CMAP). J Am Acad Child Adolesc Psychiatry 2004;43:51927. DR 11. Findling RL, Reed MD, O’Riordan MA, Demeter CA, Stansbery RJ, McNamara NK. Effectiveness, safety, and pharmacokinetics of quetiapine in aggressive children with conduct disorder. J Am Acad Child Adolesc Psychiatry 2006;45:792-800. 12. Gleason MM, Egger HL, Emslie GJ, et al. Psychopharmacological treatment for very young children: contexts and guidelines. J Am Acad Child Adolesc Psychiatry 2007;46:1532-1572. 13. Greenhill LL, AACAP Work Group on Quality Issues. Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry 2002; 41(supplement):26S-49S. 14. Gould MS, Walsh BT, Munfakh JL, et al. Sudden Death and Use of Stimulant Medications in Youths. Am J Psychiatry. 2009. 166: 9921001 15. Hughes CW, Emslie GJ, Crismon ML, et al. The Texas childhood medication algorithm project: revision of the algorithm for medication treatment of childhood major depressive disorder. J Am Acad Child Adolesc Psychiatry 2007; 46(6):667-686. 16. Jensen PS, Builelaar J, Pandina GJ, Binder C, Haas M. Management of psychiatric disorders in children and adolescents with atypical antipsychotics. Eur Child Adolesc Psychiatry 2007:16:104-120. 17. Jensen PS and the T-MAY Steering Committee. Treatment of Maladaptive Behavior in Youth (T-MAY). Center for Education and Research on Mental Health Therapeutics (CERT), Rutgers University, New Brunswick, NJ, 2010; 39 pp. 18. Kowatch RA, DelBello MP. The use of mood stabilizers and atypical antipsychotics in children and adolescents with bipolar disorders. CNS Spectrum 2003;8:273-80. 19. Kutcher SP. Practical child & adolescent psychopharmacology. Cambridge University Press, Cambridge, UK, 2002; 457 pp. 20. Martin A, Scahill L, Charney DS, Leckman JF (eds). Pediatric Psychopharmacology: Principles and Practice. Oxford University Press, New York, NY, 2003. September 2010 Psychotropic Medication Utilization Parameters 11 References (continued) 21. Pappadopulos E, MacIntyre JC, Crismon ML, Findling RL, Malone RP, Derivan A, Schooler N, Sikich L, Greenhill L, Schur SB, Felton C, Kanzler H, Rube D, Sverd J, Finnerty M, Ketner S, Siennick SE, Jensen PS. Treatment recommendations for the use of antipsychotics for aggressive Youth (TRAAY): Part II. J Am Acad Child Adolesc Psychiatry 2003;42:145-61. 22. Patel NC, Crismon ML, Hoagwood K, Jensen PS. Unanswered questions regarding antipsychotic use in aggressive children and adolescents. Jour Child & Adolesc Psychopharm 2005;15:270-284. 23. Pavuluri MN, Henry DB, Devineni B, Carbray JA, Naylor MW, Janicak PG. A pharmacotherapy algorithm for stabilization and maintenance of pediatric bipolar disorder. J Am Acad Child Adolesc Psychiatry 2004;43:859-67. 24. Perrin JM, Friedman RA, Knilans TK, et al. Cardiovascular monitoring and stimulant drugs for Attention Deficit/Hyperactivity Disorder. Pediatrics 2008;122:451-453. T 25. Pliszka SR. Non-stimulant treatment of attention-deficit hyperactivity disorder. CNS Spectrums 2003;8:253-58. 26. Pliszka SR, Crismon ML, Hughes CW, Conners CK, Emslie GJ, Jensen PT, McCracken JT, Swanson JM, Lopez M, and the Texas Consensus Conference Panel on Pharmacotherapy of Childhood Attention Deficit/Hyperactivity Disorder. The Texas Children’s Medication Algorithm Project: A revision of the algorithm for the pharmacotherapy of childhood Attention Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry 2006;45:642-57. AF 27. Pliszka SR, Lopez M, Crismon ML, Toprac M, Hughes CW, Emslie GJ, Boemer C. A feasibility study of the Children’s Medication Algorithm Project (CMAP) algorithm for the treatment of ADHD. J Am Acad Child Adolesc Psychiatry 2003;42:279-87. 28. Prescribing psychoactive medications for children and adolescents: Policy Statement, American Academy of Child and Adolescent Psychiatry, Revised and approved by the Council, September 20, 2001, http://www.aacap.org/cs/root/policy_statements/prescribing_psychoactive_medication_for_children_and_adolescents 29. Psychiatric care of children in the foster care system: Policy Statement, American Academy of Child and Adolescent Psychiatry, Revised and approved by the Council, September 20, 2001, http://www.aacap.org/cs/root/policy_statements/psychiatric_care_of_children_in_the_foster_care_system DR 30. Rush AJ, First MB, Blacker. Handbook of Psychiatric Measures; 2nd ed. Washington, DC. American Psychiatric Pub. 2008. 31. Scahill L, Oesterheld, JR. Martin A. Pediatric psychopharmacology II. General principles, specific drug treatments, and clinical practice. In: Lewis M (ed.). Child and adolescent psychiatry: A comprehensive textbook. Lippincott Williams & Wilkins, Philadelphia, 2007: 754-788. 32. Schur SB, Sikich L, Findling RL; Malone RP, Crismon ML, Derivan, A, MacIntyre II JC, Pappadopulos E, Greenhill L, Schooler N, Van Orden K, Jensen PS. Treatments for aggression in children and adolescents: a review. J Am Acad Child Adolesc Psychiatry 2003;42:132-44. 33. Sikich L, Frazier JA, McCelellan J, et al. Double-Blind Comparison of First- and Second-Generation Antipsychotics in Early-Onset Schizophrenia and Schizoaffective Disorder: Findings from the Treatment of Early-Onset Schizophrenia Spectrum Disorders (TEOSS) Study. Am J Psychiatry. 2008;165(11): 1420-31. 34. Swanson J, Arnold LE, Kraemer H. Evidence, Interpretation, and Qualification From Multiple Reports of Long-Term Outcomes in the Multimodal Treatment Study of Children With ADHD (MTA): Part I: Executive Summary. J Atten Disord. 2008.12: 4-14. 35. Vitiello B. Understanding the Risk of Using Medications for Attention Deficit Hyperactivity Disorder with Respect to Physical Growth and Cardiovascular Function. Child and adolescent psychiatric clinics of North America. 2008. 17(2):459-474. 36. Wagner KD, Pliszka SR. Treatment of child and adolescent disorders. In: Schaztzberg AF, Nemeroff CB (eds). Textbook of psychopharmacology, 4th. Ed. American Psychiatric Publishing, Washington, DC, 2009: 1309-1371. Recommendations for primary care providers on when to seek referral or consultation with a child psychiatrist can be found at http://www.aacap.org/cs/root/physicians_and_allied_professionals/when_to_seek_referral_or_consultation_with_a_child_and_adolescent_psychiatrist September 2010 Psychotropic Medication Utilization Parameters 12 Stimulants Drug Initial Dosage Literature Based Maximum Dosage FDA Approved Maximum Dosage for Children and Adolescents Amphetamine Mixed Salts Generic available 5 mg/day 40 mg/day (30 mg/day-XR) 40 mg/day Adderall® Adderall®XR ** Methylphenidate Generic available Ritalin® Ritalin®SR Ritalin®LA Metadate® Metadate®CD 40 mg/day Not recommended in children younger than 6 years IR: Once or twice daily Spansule: Once daily 30mg/day 70mg/day 70mg/day Not studied in children younger than 6 years Once daily Abuse potential Ritalin IR: 10 mg/day Not recommended for children younger than 6 years Ritalin SR: 5 mg/day Ritalin LA: 20 mg/day Metadate: 10mg/day Methylin: 10mg/day 60 mg/day (30mg/dayDaytrana TD) (90mg/dayConcerta) Over 6 years: Ritalin, Metadate, and Methylin: 60 mg/day Concerta: Children: 54 mg/day Adolescents: 72 mg/day Ritalin IR: One to three times daily Sudden death and serious cardiovascular events Ritalin SR: Once daily Metadate: Twice daily • Sudden death in those with pre-existing structural cardiac abnormalities or other serious heart problems • Hypertension • Psychiatric adverse event • Long-term growth suppression Metadate CD: Once daily Methylin: Twice daily DR Methylin® SR: Once daily AF Lisdexamfetamine Vyvanse® Not recommended in children younger than 3 years 40 mg/day Dexedrine Spansule® Warnings and Precautions IR: Once or twice daily 5 mg/day Dexedrine® Black Box Warning * T Dextroamphetamine Generic available (30 mg/day-XR) Schedule Methylin®ER Concerta® Daytrana® TD Dexmethylphenidate Concerta: 18mg/day Daytrana: 30 mg/day (largest patch) DaytranaTD: 10 mg/day 5 mg/day 20 mg/day Methylin ER: Once daily Concerta: Once daily Daytrana TD: Once daily Focalin 20 mg/day IR: Twice daily Focalin® Focalin XR 30 mg/day XR: Once daily Focalin® XR Not recommended for children younger than 6 years * See the FDA approved product labeling for each medication for the full black box warnings. ** IR, immediate-release; SR, sustained-release formulation; CD, combined immediate release and extended release; ER and XR, extended-release; TD, transdermal. September 2010 Psychotropic Medication Utilization Parameters 13 Other ADHD Treatments Drug Initial Dosage Literature Based Maximum Dosage FDA Approved Maximum Dosage for Children and Adolescents Atomoxetine Children: 0.5 mg/kg/day Children: 1.4 mg/kg/day Children: 1.4 mg/kg Adolescents: 40 mg/day Adolescents: 80-100 mg/day 0.05 mg/day 0.4 mg/day 0.5 mg/day 4 mg/day Bupropion Generic available Children: 75 mg/day Wellbutrin® Wellbutrin®SR Wellbutrin®XL Adolescents: 100-150 mg/ day The lesser of:3-6 mg/kg/ day OR 400 mg/day (SR) Clonidine Generic available Tenex® Intuniv® Maximum dosage should not exceed 1.4 mg/kg/day or 100 mg/day, whichever is less Not approved for children and adolescents Sustained release (brand name Intuniv™) approved for treatment of ADHD in children and adolescents up to 4mg/day 450 mg/day (XL) Not approved for children and adolescents Sustained or extended release formulation is recommended. Sustained release tablets may be halved prior to administration; however, partial tablets will degrade upon prolonged atmospheric exposure. DR Extended release tablets cannot be split prior to administration. Imipramine Generic available Tofranil® 1 mg/kg/day Nortriptyline Generic available Aventyl® Pamelor® Nortrilen® Once or twice daily None Black Box Warning Suicidal thinking in children and adolescents being treated for ADHD Once to four times daily 0.5 mg/kg/day 4 mg/kg/day OR 300 mg/day (Adolescents) 2.5 mg/kg/day OR 150 mg/day (Adolescents) Warnings and Precautions • Liver injury • Serious cardiovascular events, including sudden death, particularly in those with pre-existing structural cardiac abnormalities or other serious heart problems • Increases in blood pressure and heart rate • Psychiatric adverse events Once to four times daily None None Approved for treatment of enuresis in children 6 years and older 2.5 mg/kg/day Not approved for children and adolescents IR: Once to three times daily None SR: Once to twice daily XL: Once daily Twice daily • Pulse • ECG Twice daily • Pulse • ECG September 2010 • Sedation • Hypotension None AF Catapres® Guanfacine Generic available Adolescents: 100 mg/day Baseline/ Monitoring T Strattera® Schedule Increased risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders • Use in combination with MAOIs • Suicidal ideation • Activation of mania/hypomania • Discontinuation syndrome • Increased risk of bleeding Psychotropic Medication Utilization Parameters 14 Antidepressants, SSRIs Drug Starting Dose Initial Target Dose Literature Based Maximum Dosage FDA Approved Maximum Dosage for Children and Adolescents Citalopram Generic available Children: 10-20 mg/day Children: 20 mg/day Children: 40mg/day Celexa® Adolescents: 10-20mg/day Adolescents: 20 mg/day Adolescents: 40mg/day Escitalopram Lexapro® Children: 5-10 mg/day Children: 10 mg/day Children: 20mg/day Not approved for children Adolescents: 5-10 mg/day Adolescents: 10 mg/day Adolescents: 20mg/day Adolescents 20 mg/day Fluoxetine Generic available Children: mg (or less)/day Children: 10-20 mg/day Children: 30-60mg/day Prozac® Adolescents: 10-20 mg/day Adolescents: 10-20 mg/day Adolescents: 60mg/day Approved for pediatric patients 8 to 18 years Schedule Patient Monitoring Parameters Black Box Warning Warnings and Precautions T Not approved for children and adolescents 1) Pregnancy test – as clinically indicated Increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders AF For MDD 20 mg/day Once daily For OCD 60 mg/day Paroxetine Generic available Children: Not Recommended Children: Not Recommended Children: Not Recommended Paxil® Paxil CR® Adolescents: 10-20mg/day Adolescents: 10-20 mg/day Adolescents: 40 mg/day Not approved for children and adolescents 2) Monitor for emergence of suicidal ideation or behavior • Use in combination with MAOIs • Suicidal ideation • Activation of mania/ hypomania • Discontinuation syndrome • Increased risk of bleeding or 37.5 mg/day for Paxil CR® Children: 25mg/ day Children: 25-75 mg/day Children: 200 mg/day Zoloft® Adolescents: 25-50 mg/day Adolescents: 50-150 mg/day Adolescents: 200 mg/day Approved for treatment of OCD in children and adolescents 200 mg/day DR Sertraline Generic available From Black Box Warning on package inserts: Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. Both patients and families should be encouraged to contact the clinician if depression worsens, the patient demonstrates suicidal behavior or verbalizations, or if medication side effects occur. The appropriate utilization of non-physician clinical personnel who are knowledgeable of the patient population can aid in increasing the frequency of contact between the clinic and the patient/parent. September 2010 Psychotropic Medication Utilization Parameters 15 Antidepressants, SNRIs Duloxetine Cymbalta® Literature Based Maximum Dosage Children: Insufficient Evidence Children: Insufficient Evidence Adolescents: Insufficient Evidence Adolescents: Insufficient Evidence Children: Insufficient Evidence Children: Insufficient Evidence Adolescents: Insufficient Evidence Adolescents: Insufficient Evidence FDA Approved Maximum Dosage for Children and Adolescents Schedule Patient Monitoring Parameters Black Box Warning Warnings and Precautions 1) Pregnancy test – as clinically indicated. Not approved for children and adolescents Insufficient Evidence 2) Blood pressure during dosage titration and as clinically necessary 3) Monitor for emergence of suicidal ideation or behavior T Venlafaxine Extended Release Effexor XR® Starting Dose 1) Pregnancy test – as clinically indicated Not approved for children and adolescents Insufficient Evidence 2) Blood pressure prior to initiating treatment, during dosage titration, and as clinically indicated Increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders • Use in combination with MAOIs • Suicidal ideation • Activation of mania/hypomania • Discontinuation syndrome • Increased risk of bleeding AF Drug 3) Hepatic function testing – baseline and as clinically indicated 4) Monitor for emergence of suicidal ideation or behavior Children: Insufficient Evidence Children: Insufficient Evidence Adolescents: Insufficient Evidence Adolescents: Insufficient Evidence 1) Pregnancy test – as clinically indicated Not approved for children and adolescents Insufficient Evidence 2) Blood pressure prior to initiating treatment, during dosage titration, and as clinically indicated DR Desevenlafaxine Pristiq® 3) Hepatic function testing – baseline and as clinically indicated 4) Monitor for emergence of suicidal ideation or behavior From Black Box Warning on package inserts: Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. Both patients and families should be encouraged to contact the clinician if depression worsens, the patient demonstrates suicidal behavior or verbalizations, or if medication side effects occur. The appropriate utilization of non-physician clinical personnel who are knowledgeable of the patient population can aid in increasing the frequency of contact between the clinic and the patient/parent. September 2010 Psychotropic Medication Utilization Parameters 16 Antipsychotics: Second Generation (Atypical) † Drug Aripiprazole Abilify® Initial Dosage Literature Based Maximum Dosage Children: 2.5 mg/day Children: 15mg/day Adolescents: 5 mg/day Adolescents: 30mg/day FDA Approved Maximum Dosage for Children and Adolescents Approved for Bipolar Mania or Mixed Episodes in pediatric patients (10 to 17 years) and Schizophrenia in adolescents (13-17 years) 30mg/day Schedule Once daily Children: 300 mg/day Adolescents: 25 mg/day Adolescents: 600 mg/day Children: 2.5 mg/day Children: 12.5 mg/day Adolescents: 2.5-5 mg/day Adolescents: 30 mg/day Risperidone Generic available Children: 0.25 mg/day Children: 1.5-2 mg/day Risperdal® Adolescents: 0.5 mg/day Adolescents: 2-6 mg/day Seroquel® Approved Bipolar Mania (1017 years) and for Schizophrenia in adolescents (13-17 years) 600mg/day Once to twice daily Not approved for children Zyprexa® Approved for Bipolar Mania or Mixed Episodes and Schizophrenia in adolescents (13-17 years) 20mg/day Once to twice daily Not approved for children Approved for Bipolar Mania or Mixed Episodes in children and adolescents (10-17 years) and Schizophrenia in adolescents (13-17 years) 6 mg/day Once to twice daily Irritability associated with Autistic Disorder (5-16 years) 3 mg/day Children: 6.25-12.5 mg/day Children: 150-300 mg/day Clozaril® Fazaclo® Adolescents: 6.2525 mg/day Adolescents: 200-600 mg/day Not approved for children and adolescents Once daily DR Clozapine Generic available Asenapine (sublingual) Insufficient Evidence Insufficient Evidence Not approved for children and adolescents Insufficient Evidence Insufficient Evidence Insufficient Evidence Not approved for children and adolescents Insufficient Evidence Insufficient Evidence Insufficient Evidence Not approved for children and adolescents Insufficient Evidence Children: 10 mg/day Children: Insufficient Evidence Not approved for children and adolescents Adolescents: 20 mg/day Adolescents: 160 mg/day Saphris® Iloperidone Fanapt® Paliperidone Invega® Ziprasidone Geodon® 4) Fasting plasma glucose level or hemoglobin A1c – before initiating a new antipsychotic, then yearly. If a patient has significant risk factors for diabetes and for those that are gaining weight – before initiating a new antipsychotic, 4 months after starting an antipsychotic, and then yearly. 5) Lipid screening [total cholesterol, lowand high-density lipoprotein (LDL and HDL) cholesterol, and triglycerides] – Every 2 years or more often if lipid levels are in the normal range, every 6 months if the LDL level is > 130 mg/dl Twice daily (Better absorbed when taken with food) 6) Sexual function inquiry – inquire yearly for evidence of galactorrhea/ gynecomastia, menstrual disturbance, libido disturbance or erectile/ejaculatory disturbances in males. If a patient is receiving an antipsychotic known to be associated with Prolactin elevation, then at each visit (quarterly for inpatients) for the first 12 months after starting an antipsychotic or until the medication dose is stable and then yearly 7) EPS Evaluation (examination for rigidity, tremor, akathisia) – before initiation of any antipsychotic medication, then weekly for the first 2 weeks after initiating treatment with a new antipsychotic or until the dose has been stabilized and weekly for 2 weeks after a dose increase. 8) Tardive Dyskinesia evaluation – every 12 months. For high risk patients (including the elderly), every 6 months.. 9) Vision questionnaire – ask whether the patient has experienced a change in vision and should specifically ask about distance vision and blurry vision – yearly 10) Ocular evaluations – every 2 years in youth ‡ 11) EKG – Baseline and as clinically indicated (Asenapine, Iloperidone, Paliperidone and Ziprasidone) § Warnings and Precautions Not approved for depression in under age 18. Increased the risk of suicidal thinking and behavior in short-term studies in children and adolescents with major depressive disorder and other psychiatric disorders None related to youth AF Olanzapine 3) Weight and BMI measurement – when a new antipsychotic is initiated, at every visit (monthly for inpatients) for 6 months after the new antipsychotic is initiated, and quarterly when the antipsychotic does is stable. Black Box Warning T Children: 12.5 mg/day 1) CBC as indicated by guidelines approved by the FDA in the product labeling. 2) Pregnancy test – as clinically indicated Irritability associated with autistic disorder (6-17 years) 15mg/day Quetiapine Patient Monitoring Parameters • Neuroleptic Malignant Syndrome • Tardive Dyskinesia • Hyperglycemia and Diabetes Mellitus • Weight gain • Akathisia • Dyslipidemia None related to youth Agranulocytosis; seizures; myocarditis; other adverse cardiovascular and respiratory effects None related to youth None related to youth None related to youth Not approved for depression in under age 18. Increased the risk of suicidality in short-term studies in children and adolescents with major depressive disorder and other psychiatric disorders • Neuroleptic Malignant Syndrome • Tardive Dyskinesia • Hyperglycemia and Diabetes Mellitus • Weight gain • Akathisia • Dyslipidemia • Prolonged QTc interval † Dosage recommendations in this table are based on reference # 17 (Jensen, 2010). ‡ There is no current clinical consensus regarding the need for routine ocular evaluations in children and adolescents. Data from animal studies suggest that quetiapine might be associated with increased risk of cataract development, but this has not been concluded from current evidence in human use. § There is no current clinical consensus regarding the need for routine monitoring of QTc interval with use of Ziprasidone in children and adolescents. For additional information regarding EKG monitoring with Ziprasidone use, please refer to reference # 4 (Blair, 2005). September 2010 Psychotropic Medication Utilization Parameters 17 Antipsychotics: First Generation (Typical) Drug Starting Dose Literature Based Maximum Dosage FDA Approved Maximum Dosage for Children and Adolescents Schedule Black Box Warning Chlorpromazine Generic available Child 0.275 mg/kg None related to youth Adolescent 12.5 mg Approved for treatment of severe behavioral problems in children (6 months to 12 years) Two to four times daily Thorazine® Chidlren younger than 5 years 40 mg/day Children 5-12 years 75mg/day Adolescent 800 mg/day Warnings and Precautions • May alter cardiac conduction • Sedation • Orthostatic hypotension • EPS • Tardive Dyskinesia • Neuroleptic Malignant Syndrome • Use caution with renal disease, seizure disorders, respiratory disease, and any acute illness in children • Weight gain Outpatient Children: 0.25mg/pound every 4-6 hours Inpatient Children: 200mg/day in older children Haldol® <35 kg: 0.25-0.5mg/ day ≥35 kg: 1 mg/day <35 kg: 3-4 mg/day ≥35 kg: 10 mg/day Approved for treatment of Psychotic Disorders, Tourette’s Disorder, and severe behavioral problems in children 3 years and older Once to three times daily None related to youth AF Haloperidol Generic available T Adolescents 800 mg/day Psychosis: 0.15mg/kg/day Tourette’s and severe behavioral problems: 0.075mg/kg/day • Sedation • Orthostatic Hypotension • EPS • Photosensitivity • Tardive Dyskinesia • Constipation • Dry Mouth • Tachycardia • Prolactin elevation 6mg/day Perphenazine Generic Available 6-12 years: 6 mg/day Adolescents: 64 mg/day Approved for treatment of psychotic disorders in 12 years and older Three times a day Pimozide Orap® 1-2 mg/day ≤ 12 years 0.2 mg/kg/d 10 mg/day None related to youth • EPS • Tardive Dyskinesia • Dystonia • Neuroleptic Malignant Syndrome • Orthostatic hypotension • May alter cardiac conduction • Endocrine changes • Weight gain None related to youth • EPS • Tardive Dyskinesia • Dyskinesias • Dry Mouth • Constipation • Prolactin Elevation • Prolongs QTc interval 64mg/day DR Trilafon® ≥ 12 years old 12 mg/day Approved for treatment of Tourette’s Disorder in 12 years and older Once to twice daily 10mg/day Chlorpromazine and Haloperidol, when prescribed for severe behavioral problems, should be reserved for children with who have failed to respond to psychotherapy or medications other than antipsychotics. September 2010 Psychotropic Medication Utilization Parameters 18 Mood Stabilizers Drug Initial Dosage Target Dose or Range Carbamazepine Generic available Under 6 years: 10-20mg/kg/ day Under 6 years: 35mg/kg/day Carbatol® Tegretol® Tegretol® XR 6-12 years: 100mg twice a day 12 years and older: 200mg twice a day Literature Based Maximum Dosage FDA Approved Maximum Dosage for Children and Adolescents Schedule Approved for Seizure Disorders in all ages Immediate Release two to four times a day Maximum dosages Under 6 years: 35 mg/kg/day 6-12 years: 400-800mg/day • CBS • Electrolytes Sustained Release (XR) twice a day 6-12 years: 800mg/day 12 years and older: 800-1200mg/day Baseline Monitoring Black Box Warning Warnings and Precautions StevensJohnson syndrome Aplastic Anemia/ Agranulocytosis • Aplastic Anemia • Neutropenia • Hyponatremia • Induces metabolism of itself and some other drugs • Decreased efficacy of oral contraceptives • Teratogenicity • Stevens-Johnson Syndrome 12-15 years: 1000 mg/day Divalproex Sodium Generic available 250mg/day 500mg-2000mg/day Lithium Generic available Eskalith® Eskalith®CR Approved for Seizure Disorders in 10 years and older Frequency: Day 7 • Weekly until stable • q6 months thereafter Maximum dose based upon serum level. Maximum dose based upon serum level. Approved for manic episodes and maintenance of Bipolar Disorder in 12 years and older Two to three times daily • Chemistry Panel • CBC (with platelets) • LFTs • Pregnancy test Hepatotoxicity; Teratogenicity; Pancreatitis Children: 15-20 mg/kg/ day in two to three divided doses Adolescents: 300mg three time daily (or 900mg/day) Dose adjustment based upon serum level. Serum level: 0.4-0.6 mEq/L Note: 300mg Lithium Carbonate increases serum level by 0.2 – 0.4mEq/L Serum level: 0.6 – 1.2 mEq/L Frequency of blood level monitoring: • Day 7 • Weekly until stable • q3 months thereafter Serum level: 50-100 mcg/ml or 60 mg/kg/day Lamotrigine Generic Available Children: 2-5mg/day Lamictal® Adolescents: 25mg/day (increase by 25mg every 2 weeks) Children: • with Valproate 1-3mg/kg/day • with Valproate and EIAED’s * 1-5mg/kg/day • Monotherapy 4.5-7.5mg/kg/day • with EIAED’s 5-15mg/kg/day Adolescents: • with Valproate 100-200mg/day • with Valproate and EIAED’s 100-400mg/day • Monotherapy 225-375mg/day • with EIAED’s 300-500mg/day Once to three times daily Maximum dose Serum level: 1.2 mEq/L DR Lithobid® Range: 50-120 mcg/ ml AF Depakote® T >15 years: 1200 mg/day Approved for adjunctive therapy for Seizure Disorders in 2 years and older Maximum dose 500 mg/day • Chemistry Panel • CBC (with platelets) • Serum Creatinine • TFTs • Pregnancy test • ECG Once to twice daily initially, then twice daily for maintenance Safety and effectiveness for treatment of Bipolar Disorder in patients below 18 years has not been established * EIAED’s - Enzyme Inducing Anti-Epileptic Drugs (e.g. Carbamazepine, Phenobarbital, Phenytoin, Primidone) September 2010 • Hepatotoxicity • Teratogenicity • Pancreatitis • Urea cycle disorders • Multi-organ hypersensitivity reaction • Thrombocytopenia • Withdrawal seizures • Suicidal ideation • Polycystic ovaries Toxicity above therapeutic serum levels • Toxicity above therapeutic serum levels • Renal function impairment • Special risk patients: those with significant renal or cardiovascular disease, severe debilitation, dehydration, sodium depletion, and to patients • Polyuria • Tremor • Diarrhea • Nausea • Hypothyroid • Teratogenic Serious rashes including StevensJohnson syndrome and asceptic meningitis • Dermatological reactions • Potential Stevens Johnson Syndrome • Acute-multi organ failure • Withdrawal seizures • Blood dyscrasias • Hypersensitivity • Suicidal ideation Psychotropic Medication Utilization Parameters 19 Glossary BMI = Body Mass Index. A measure of body fat based upon height and weight. CBC = Complete blood count. Lab test used to monitor for abnormalities in blood cells, e.g., for anemia. Serum creatinine = A lab test used to calculate an estimate of kidney function. ECG = Electrocardiogram EPS = Extrapyramidal side effects. These are adverse effects upon movement, including stiffness, tremor, and severe muscle spasm FDA = U.S. Food and Drug Administration LFTs = Live function tests AF MAOIs = Monoamine Oxidase Inhibitors T Hemoglobin A1c = A laboratory measurement of the amount of glucose in the hemoglobin of the red blood cells. Provides a measure of average glucose over several days. Prolactin = A hormone produced by the pituitary gland. DR TFTs = Thyroid Function Tests September 2010 Medicaid Managed Care for Foster Children: An Early Report Summary of a report prepared by the Center for Public Policy Priorities Children in foster care have a higher prevalence of physical health, behavioral or mental health, and developmental problems than other children from the same socioeconomic backgrounds. Approximately 60% of foster children have a chronic medical condition, 25% have three or more chronic conditions, and between 54% and 80% have diagnosable psychiatric conditions. Senate Bill 6 in 2005 directed the Health and Human Services Commission (HHSC) to create a new health care delivery model to provide foster children with comprehensive services, a “medical home,” and coordinated access to care. As a result, STAR Health, a new Medicaid managed-care model for foster children, was implemented on April 1, 2008. In addition, the federal Foster Connections to Success & Increasing Adoptions Act of 2008 requires that states improve access to and coordination of health care for foster children as a condition of maintaining federal funding. Specifically, states must ensure continuity of care, establish a medical home, oversee prescription medication, create a schedule for health screenings, and ensure that medical information is updated and appropriately shared through mechanisms which may include an electronic health record. With the implementation of STAR Health, Texas appears to already meet the act’s provisions. Before STAR Health, foster children were in traditional, fee-for-service Medicaid. Features of STAR Health include: Immediate Medicaid Eligibility where children qualify immediately upon entering conservatorship; a Medical Home with an assigned Primary Care Provider; Service Coordination to help members find providers, schedule appointments, access services, and help all involved to share information; Service Management for members with ongoing and serious health care needs; a Health Passport or web-based, electronic health care record; and Help Lines open continually to get answers to health questions. DFPS excludes certain parties from accessing the Health Passport, which is HIPAA compliant, online; however, they can view hard copies at DFPS offices. Information available includes: health care visit history, prescriptions filled, demographic data including contact information for the child, immunization history, lab results, allergies, vital signs, and forms. Service coordinators and managers work in two-person teams with one member experienced in physical health and the other in behavioral health. Service coordination can be requested by members, providers, caregivers, medical consenters, CPS caseworkers, or the court system and requests should receive a response within 24 hours. In general, STAR Health covers medically necessary physical health care, behavioral health care, dental and vision care, immunizations, hospital care, and prescription drugs. Children eligible for STAR Health include: children in DFPS conservatorship, including those placed in a relative’s home; young adults 18 to 22 who voluntarily agree to continue in their foster care placement; and young adults who age out of foster care and remain eligible for Medicaid who are under age 21 and an income cap. Foster children who are adopted maintain Medicaid eligibility, but once adoption is completed, move from STAR Health into regular Medicaid. If conservatorship is given to a parent or relative, children lose STAR Health, but may be eligible for regular Medicaid. For services in managed care, members must seek care within a defined network of providers. Managed care organizations authorize or deny requests for certain expensive services in advance based on medical necessity. They are generally paid a fixed rate paid per-person-per-month to cover health care services. The STAR Health model transfers financial risk through this system. The state’s rationale for moving foster children into managed care is to improve services, not to cut costs. The managed care system through STAR Health, however, removes some control over medical decision-making from children’s caretakers due to limited provider networks and the ability to deny requests for certain services. Although the number of potential providers decreased from all Medicaid providers to those in the STAR Health network, Superior, the managed care organization, assumed the responsibility to ensure adequate access for covered services across the state by setting several standards, including allowable waiting times for appointments, required numbers of network providers within a geographical area, and allowable percentage of out-of-network claims. Although proximity to providers is a complaint, a current evaluation of STAR Health shows 90 percent of members can access providers within distance requirements. Still, the concern heard most from an array of stakeholders was about the inadequacy of Superior’s network. There has also been confusion about which providers are in the STAR Health network. Superior was sanctioned for releasing provider directories with incorrect information. Caretakers can now search for participating providers using Superior’s online provider search function. Superior’s provider contracts require Primary Care Physicians (PCP) to assess the medical and behavioral health needs of members; provide referrals for specialty care; submit forms to the Health Passport; and be accessible (calls returned with in 30 minutes) 24 hours a day, 7 days a week. Provider contracts allow specialists to act as a PCP for members with special health care needs. Members may change their PCP at any time. Superior is required to contract with various behavioral health providers to meet the needs of members, including providers who specialize in treating child victims of neglect and physical or sexual abuse. STAR Health behavioral health providers, following the first 10 behavioral health visits, must get periodic prior authorizations from the STAR Health HMO for outpatient therapy visits. The required authorizations occur at more frequent intervals and may receive more scrutiny than under fee-for-service Medicaid. STAR Health services that require prior authorization from Superior include out-of-network services and inpatient hospitalizations (except emergencies), certain rehabilitative therapies, visits to certain specialists, and ongoing outpatient behavioral health care visits. Superior’s provider handbook notes that it will respond to providers’ requests for prior authorization within 48 hours. Superior created a pre-appeals process for services requested through prior authorization, where a service manager will attempt to get additional information. If medical necessity is still in question, Superior’s medical director or a consulting physician will make at least two attempts to conduct a peer-to-peer review with the PCP to discuss clinical information or alternative treatment options. All STAR Health providers are required to comply with Psychotropic Medication Utilization Parameters for Foster Children. Since these guidelines were released early in 2005, psychotropic medication usage by foster children has decreased. Compliance is monitored on children age 4 and under on psychotropic medication, children on five or more medications, and children on a psychotropic medication without a behavioral health diagnosis. Superior’s contracts with providers require that they testify in court when needed, but the state has no process to reimburse them for that service which may be a deterrent for provider participation. By contract, Superior must authorize and reimburse all court-ordered care that is a benefit of Texas Medicaid. This includes instances when a judge orders care from a specific provider not in Superior’s network as long as the provider accepts Medicaid. Judges may contact STAR Health judicial liaisons by calling (512) 466-4102 or sending email to [email protected]. Need More Information? The Center for Public Policy Priorities (CPPP) full article can be found at: www.cppp.org/files/4/351%20Medicaid%20Managed%20Care%20for%20Foster%20Care.pdf 0 Psychotropic Medication Utilization Parameters for Foster Children: www.dshs.state.tx.us/mhprograms/psychotropicmedicationfosterchildren.shtm Superior’s STAR Health website: www.fostercaretx.com DFPS’ STAR Health website: www.dfps.state.tx.us/About/Renewal/CPS/medical.asp STAR Health contract: www.hhsc.state.tx.us/medicaid/STAR_Health.pdf Residential Treatment for Children and Youth Program Participants: Children and adolescents admitted to RTCs often have long-standing problems that remain unresolved despite previous attempts at remediation. These children and adolescents have often displayed a wide variety of diverse symptomatology including depression, suicide attempts/gestures, anxiety, self-destructive behaviors, psychosis, eating disturbance, truancy, running away, school phobia, lying, and extreme negativism. Some children and adolescents are struggling with serious emotional problems that have developed into patterns of life-threatening or high-risk behaviors that require intensive intervention in a contained and highly structured environment. Some children and adolescents are experiencing serious psychiatric disturbances and are in need of intensive medical intervention in the form of psychotropic medication and/or ongoing psychiatric monitoring and consultation. Others still, have longstanding relationship problems or have been unable to negotiate basic developmental stages and need long-term relationship-based treatment to remediate. Milieu Therapy: Milieu therapy is a 24 hour daily, therapeutic living environment facilitated by Residential Counselor staff. Milieu therapy is focused on providing planned structure, support, routine and a "therapeutic culture" to allow for improved daily living skills, coping skills, and interpersonal relationship skills. Trust, safety, and respect are core components of a program's approach. Family Therapy: Family therapy is provided on a weekly basis by Master’s level clinicians. The family is an essential part of successful treatment and a critical factor in the long term success of children after they leave a program. Families are expected to take an active role in the treatment process. The goal of family therapy is to assist the family in developing improved communication and problem solving skills and to learn to more effectively understanding and meet their child’s unique emotional needs. In addition, families have the opportunity to participate in parent education and support groups. Individual Therapy: Individual therapy is provided to all children and adolescents on a twice weekly basis by Master’s level clinicians. Intensive individual therapy is a significant component of the treatment program at Residential Treatment Centers. The goal of individual therapy is to assist the child or youth in developing an improved understanding of their emotional and mental health problems, to process and work through past difficulties and traumas, and to develop skills in effectively communicating their needs and feelings, problem solving, and coping with their emotional and mental health needs. The individual therapists coordinate and consult with the Treatment Team to compliment work being done in other areas of the program. Clients also have many opportunities for informal counseling interactions with Residential Counselor staff, which serve to enhance the overall therapeutic focus of the program. Group Therapy: Group Therapy is provided to all clients on a twice per week basis. Groups are led or supervised by Master’s level clinicians and staff. Individuals are assigned to groups based upon their developmental level and clinical need. Group Therapy is ongoing and both dynamically and skill oriented. The content of the group is largely determined by the issues of its members and often involve relationships, parenting and caretaking, self-esteem, sexuality, and other normal child/adolescent or treatment issues. All clients may also participate in community meetings, which are process and skills groups that occur on the living units two times each day. These meetings are generally 45-60 minutes in length and are led by Residential Counselors. The meetings provide clients an opportunity to discuss issues related to unit functioning, rules, emotional regulation, self-soothing, and interpersonal relationships. Topics may include: Social Skills, Problem Solving Skills, Conflict Resolution Skills, Relaxation Skills, Independent Living Skills, Gender-Specific Issues, Sexual Health, Chemical Health, and Self-Esteem. Psychiatric Consultation and Medication Management: All children and youth see a Board Certified Child and Adolescent Psychiatrist as part of the initial evaluation process and on an ongoing basis. Frequency of ongoing psychiatric contact depends on each client’s specific needs. Clients are seen minimally on a monthly basis and can be seen as frequently as weekly if indicated. Most clients at Residential Treatment Centers take psychoactive medications. Treatment Plans for Mental Health Therapy is a process in which someone receives treatment for mental health issues. A treatment plan is necessary to pinpoint the exact issues being treating and the ways in which they will be addressed. It sets specific goals that allow both provider and client to access progress. It acts as an important road map, providing guidance on the road to the goals and instructions on how to reach them. Take notes that can be used to fill out the therapy plan form. Six Steps to a Successful Treatment Plan: Step 1: Treatment Goals Treatment goals should be set with the client. These goals should be as specific as possible. For example, if you are treating someone with anxiety disorder, do not use a general goal like "Reduce anxiety." Come up with specific, measurable goals like "Client will be able to comfortably approach and talk to strangers" and "Client will attend social gatherings rather than staying home due to anxiety." Step 2: Action Steps Specific steps should be developed for each of the goals. The steps should be specific actions that the client can take to accomplish each goal with a defined series of actions within a specified timeframe. Step 3: A Client-Centered Plan Steps should be discussed with the client, making appropriate changes if needed. In client-centered treatment, the steps should take the client's abilities and limitations into consideration as well as motivation and ownership. They should allow the client to have small successes that act as the foundation for bigger ones. Step 4: Timeframe A timeframe for the treatment plan should be created. The client and treatment provider should set a target to accomplish each goal. Remember, each individual step can also have a timeframe if appropriate. It is important to indicate how often progress will be assessed. Usually this is done at each counseling session, but that can be variable. Step 5: Documentation The treatment plan should be recorded on a form used the treatment provider or agency. There are generally standardized forms for treatment planning as well as progress notes. It is important that no treatment plan be applied in a “cookie cutter” fashion without individualizing the treatment to the presenting problem and client’s needs. Step 6: Treatment Teams Those serving on a client’s treatment team, especially with psychiatric hospitalization or residential treatment, may all access and add to the treatment plan so that it will represent the entire treatment process and measurable progress. FLORIDA DEPARTMENT OF JUVENILE JUSTICE SAMPLE INITIAL MENTAL HEALTH TREATMENT PLAN Child or Youth’s Name_____________________________________ DOB________________ Sex______ Race______ Facility Name ___________________________________________ 1. Reason for Mental Health Treatment: 2. Initial Diagnosis or Presenting Symptoms: Initial DSM-IV-TR Diagnoses Axis I Axis II Axis III Axis IV Axis V (GAF) Presenting Symptoms 3. Initial Treatment Methods: (Describe treatment methods, duration, amount and frequency of mental health services. For children or youths receiving psychiatric care, record: 1. Psychotropic medications currently prescribed; and 2. Frequency of monitoring by a psychiatrist). __ __ 4. Initial Treatment Goals and Objectives Goal: Objective: Goal: Objective: Goal: Objective: Youth’s Signature/Date Parent/Guardian’s Signature/Date Mental Health/Substance Abuse Clinical Staff’ Signature/Date Treatment Team Member Signature/Date Licensed Mental Health Professional’s or CAP Signature/Date Treatment Team Member Signature/Date MHSA 015 August 2006 P.O. Box 7338 • Madison, WI 53707-7338 45 Nob Hill Road • Madison, WI 53713-3959 Voice/TDD: (608) 276-4000 • (800) 279-4000 Fax: (608) 661-6706 • Web site: www.weatrust.com Outpatient Mental Health Treatment Plan Please complete this entire form and fax to the attention of Administrative Assistant, Behavioral Health, at (608) 661-6706 Clinic: Tax ID: Clinician Name, Credentials: Clinic Phone: Address: Patient Name: City: Subscriber ID: State: Zip: Fax No.: Patient DOB: First date of service: _________________ Authorization requested from date: _________________ Anticipated closure date: DSM IV Diagnosis—Axis I through V: Axis I: Code(s): Axis II: Code(s): Axis III: Axis IV (specify): Highest GAF past year: Axis V: Current GAF: Current Psychiatric Status (mark where applicable): Symptoms/Problems Depressed mood Obsessions/compulsions Anxiety Impulsiveness Somatic complaints Poor judgment Sexual issues Impaired concentration Appetite disturbance Irritability Hyperactivity Sleep disturbance Delusions Paranoia Panic attacks Hallucinations Phobias Impaired memory Alcohol abuse Opiate abuse Prescription medicine abuse Polysubstance abuse Initial date: Mild Moderate Severe Current date: Mild Moderate Severe Over ¼ Current Psychiatric Status—Risk Assessment (mark where applicable): Initial date: Mild Moderate Suicidality Homicidality Violence Severe Current date: Mild Moderate Severe Thought Plan Means Method Gesture Current Medications (Please list name, dose, date started, and compliance.): Current medications are prescribed by: Psychiatrist Primary care provider Other: Narrative Summary (Please note current level of functioning in life domains, progress made, and symptoms still in need of improvement.): (If additional space is needed, please attach your notes to this form.) Treatment Approach(es): Cognitive/behavioral DBT Solution-focused Psychoanalytical Interpersonal Other: Covered Treatment(s): Only the following procedure codes will be considered for preauthorization. Extended individual psychotherapy (beyond 50 minutes, such as 90808) requires a separate preauthorization. Total # of Sessions Frequency of Sessions A. Medication management: 2 Medication mgnt.: 90862 and/or 90805 (please circle one) 4 6 8 10 12 Other Weekly 1 in 2 wks (biweekly) Monthly Weekly 1 in 2 wks (biweekly) Monthly Other B. Psychotherapy with/without medication management: 2 Individual or family Group With medication mgmt. (up to 50 minutes) 4 6 8 10 12 Other 90804, 90806, 90847 90853 90807 Other Notes to patient: Approval of this treatment plan does not guarantee payment of benefits. Final determination is based upon plan eligibility, applicable deductibles, coinsurance, copayments, and plan limits. By signing below, you acknowledge that you have been educated about your diagnosis, its cause, and its nature and duration, and you understand your consumer role in treatment. Your signature below is requested but is not required for preauthorization of services. _______________________________________________________ (Patient’s/Guardian’s Signature if Patient is a Minor) Date ___________________________________________________________________ (Provider’s Signature) Date MHS 2970-650-0207(W) CONFIDENTIAL Mental Health Treatment Plan Area of Need: Present Level: Measurable Long-Term Goal: Parents will be informed of progress Quarterly Trimester Semester Other:_________ How? Annotated Goals/Objectives Other: ____________________ Benchmark/Short-Term Objective: Periodic Review Dates 1. ________________ 2. ________________ 3. ________________ 4. ________________ Progress Toward Goal 1. ___________________________ 2. ___________________________ 3. ___________________________ 4. ___________________________ Sufficient Progress to Meet Goal Yes No ___________________ Yes No ___________________ Yes No ___________________ Yes No ___________________ Date: Achieved Reviewed Person(s) Responsible: Benchmark/Short-Term Objective: Date: Achieved Reviewed Person(s) Responsible: Area of Need: Present Level: Measurable Long-Term Goal: Parents will be informed of progress Quarterly Trimester Semester Other:___________ How? Annotated Goals/Objectives Other: _____________________ Benchmark/Short-Term Objective: Periodic Review Dates 1. ________________ 2. ________________ 3. ________________ 4. ________________ Progress Toward Goal 1. ___________________________ 2. ___________________________ 3. ___________________________ 4. ___________________________ Sufficient Progress to Meet Goal Yes No ___________________ Yes No ___________________ Yes No ___________________ Yes No ___________________ Date: Achieved Reviewed Person(s) Responsible: Benchmark/Short-Term Objective: Date: Achieved Reviewed Person(s) Responsible: ______________________________________ ______________ ______________________________________ Student Signature Date Signature of Parent __________________________________________ Signature of Mental Health Services Representative ______________ Date ______________ Date Diana Browning Wright, Behavior/Discipline Trainings, 2002 MH Treatment plan Sample 3 CONFIDENTIAL Date: Student: Type of Service: Diana Browning Wright, Behavior/Discipline Trainings, 2002 Start Date: Duration: MH Treatment plan Sample 3 Mental Health Treatment Plan Patient Name: Patient ID#: Date: Problem #1: Current Impairments/ As Evidenced By: Long Term Goal: Short Term Objectives: Interventions: Referrals/Resources Recommended: Bibliotherapy Journaling Adjunct Treatment Support Group/Community Resource Other Homework Addiction/Dependency Referral Psychiatrist Support Group/Community Resource Other Homework Addiction/Dependency Referral Psychiatrist Problem #2: Current Impairments/ As Evidenced By: Long Term Goal: Short Term Objectives: Interventions: Referrals/Resources Recommended: Bibliotherapy Journaling Adjunct Treatment Anticipated Frequency of Visits: ___Weekly Biweekly Monthly Other: Anticipated Length of Treatment Episode: ___________________________ This plan has been discussed with the patient who reasons agrees with the plan Patient/Parent/Guardian (optional) Date Practitioner Signature (required) Date objects to the plan for the following Revised 5/7/98 Ask if provider has a mechanism to refer for a second opinion. No Ask why diagnosis is different from previous diagnoses (if applicable.) No Ask how diagnosis has ruled out other possibilities like a reaction to trauma, grief, loss No Ask how diagnosis reflects presenting problem No Do I understand the diagnosis? Yes Yes Yes Yes Ask about inclusion of family members/siblings Ask about frequency of different therapies What methods of treatment are prescribed? Do I understand the treatment process? Advocacy Questions Tree for Provider Yes Ask about specific needs of the child Ask to be involved in staffings / team meetings Ask how the provider will measure progress Do I understand how to monitor/ advocate? Advocating For Children with Emotional Problems Some nine million children have serious emotional problems at any point in time. When parents, advocates or teachers suspect that a child may have an emotional problem, they should seek a comprehensive evaluation by a mental health professional specifically trained to work with children and adolescents. Throughout the evaluation process, you should be directly involved and ask many questions. It's important to make sure you understand the results of the evaluation, the child's diagnosis, and the full range of treatment options. If you are not comfortable with a particular clinician, treatment option, or are confused about specific recommendations, ask the questions you need to ask and, if needed, consider a second opinion. You may want to ask the following: What are the recommended treatment options for the child? How will family be involved with the child's treatment? How will we know if the treatment is working? How long should it take before I see improvement? Does the child need medication? What are potential side effects of any medication? How will we know if the medication is working? What should I do if the problems get worse? What are the arrangements if I need to reach you after-hours or in an emergency? You may also need to advocate for the child to be seen in a timely way, by the most appropriate clinician. Most insurance plans now include some form of managed care, which may utilize provider panels with few mental health professionals. However, many states now have laws concerning reasonable access to specialists. If you have problems or questions, try calling the Department of Insurance, the Patient Ombudsman/Advocate, or the Department of Consumer Affairs at the insurance company. Depending on the nature of the child's problems, it may also be important to involve the school, community agencies, and/or juvenile justice system. In addition, it may be helpful to learn how to access other support services such as respite, parent skill building, or home-based programs. Local advocacy groups can also provide valuable information, experience and support. Although serious emotional problems are common in childhood and adolescence, they are also highly treatable. By advocating for early identification, comprehensive evaluation and appropriate intervention, you can make sure children get the help they need, and reduce the risk of long term emotional difficulties. For more information about advocacy, contact: National Alliance of the Mentally Ill Colonial Place Three (703) 524-7600 2107 Wilson Blvd-3rd Floor Arlington, VA 22201 http://www.nami.org National Mental Health Association (703) 684-7722 1021 Prince Street Alexandria, VA 22314-2971 http://www.nmha.org Copyright ©2009 - American Academy of Child Adolescent Psychiatry. All Rights Reserved. Checklist: Advocating for a child/youth placed in a RTC RTCs are not an appropriate long-term placement. Will the RTC focus on treatment on the issues that brought them into care or will they focus on current issues that arise during placement? For children in foster care, there is often no continuity of services. Have I kept a record or can I now retrieve a copy of all previous treatment plans and if treatment was effective as well as what medications were prescribed and taken and if medications were effective? Good communication is key to effective advocacy. Am I in regular contact with the case manager, therapist, teacher and other pertinent staff at the RTC? Do I know when the next “staffing” or “team meeting” is scheduled and if I can attend in person or via conference call? Getting the big picture is often difficult when multiple people serve on the treatment team. Do members of the interdisciplinary team have the same information? Have the same or different opinions? Observe the same or different behaviors? Have consistent notes/reports? The child/youth placed in a RTC may be cut off from family, siblings, relatives, previous caretaker. Have I established how often I will: visit, call, send cards and letters. The treatment modalities (such as individual therapy, group therapy, family therapy) may vary at each RTC. What is being offered to the child/youth? What is the frequency of each? Is it adequate to address their issues and prepare them for discharge? Medication prescribed to children/youth in foster care should be closely monitored. Do I have a list of their current medications, who prescribed them, dosage, and understand what condition each medication was prescribed to treat? An RTC is a restrictive, institutionalized setting. This does not constitute a “normal” life for a child or youth. How can I advocate for activities, relationships, social supports, education that will normalize life for the child/youth. Direct care staff at a RTC spend the most time with residents. They are also the least trained, skilled and educated members of the treatment team. Direct care staff or shift staff may be taught how to restrain a child without understanding how to de-escalate or diffuse a child in distress that would avoid restraint. I need to understand what kind of physical restraint system is used at the RTC and how long it each incident is to last. Some children and youth may be at increased risk for abuse in this setting. Do I have open-ended questions (not leading questions) I can ask of the child/youth about their experience in the RTC? Any placement change is disruptive. While I want to see the child/youth in the least restrictive environment possible, if they need continued service at the RTC but are at risk of discharge because their behaviors are improved, can I partner with the RTC to advocate a placement change decision be made based on a clinical recommendation and not the child’s LOC? Does the child/youth know their rights? Checklist: Advocating for Special Needs Aging Out Will a youth in this RTC be offered services to help them transition such as: Preparation for Adult Living (PAL) classes, Circle of Support, Transition Plan Meeting? Is the RTC going to assist in helping the youth find a place to live upon discharge? What accommodation can the RTC make so that I can help the youth with preparation for independent living? Will the teacher discuss a GED certificate, application to college or vocational school, financial aid and tuition waivers? Will the youth have the needed documents and identification card upon discharge? Education What is the quality of the educational program at the RTC? How does their school rank with the state (unacceptable, acceptable, recognized, exemplary)? What method will the teacher use to understand the current academic level of functioning of the child/youth? Will they have an Independent Education Plan (IEP) to move them from the current level of functioning to age appropriate performance (if possible)? What services are available (for special education, tutoring, speech therapy, etc.)? Will they hold an ARD? How will the plan to transition the child to the next school? What contact will they have with that school? Disabilities What medical facility is closest to the RTC? What MD do they use for medical visits, emergencies, services? How/when are referrals made? Is the MD a pediatrician? How does the RTC plan to accommodate for a particular disability? Is occupational therapy available? What specialists are available in the area and do they take the child/youth’s insurance? Tips for Providing Experiential Life Skills Training in Residential Treatment Settings All youth growing up in foster care need to receive hands-on training in life skills to help prepare them for their transition to adulthood. However, when youth are living in RTCs or other structured settings, it can take some creativity to provide experiential activities that meet the needs of youth within the setting, particularly youth who require a more restricted environment. Activities should be individually tailored to a youth's skills and abilities and can include practical skills. Here are some tips for activities to help you start thinking of ways to provide experiential activities. These tips are a product of the House Bill 1912 (81st Legislative Session) workgroup and they were developed to help caregivers fulfill the requirement of providing or assisting foster youth age 14 or older in obtaining experiential life-skills training to improve their transition to independent living. FOOD AND MEALS Preparing Food: In some residential settings, only people who have received Food Handler’s Certification are allowed to prepare food in the facility kitchen. Even if this is not the case, it may not be in the best interest of the youth to expose them to kitchen utensils and appliances that may be used in a harmful manner. However, youth need to learn how to prepare their own food. One way to provide an experiential activity in food preparation is to take the lesson outside of the kitchen to a classroom or other appropriate setting and prepare something simple that does not require cooking, such as trail mix or smoothies. A simple recipe can be utilized to teach how to use recipes and follow written directions, such as on packages of ready-to-prepare foods. Youth can receive experience in using measuring cups and spoons and mixing bowls. This is also a great time to discuss nutrition. Meal Planning: Youth can find a recipe they like in a cookbook, online, or in a magazine. They can make a list of ingredients to plan a meal for an individual and then another for making a meal for a group. If youth are able to go grocery shopping to purchase items, have them take a calculator and budget along with the list. Challenge: give each youth a few dollars to utilize for a meal and go to the grocery store with a group of youth. They can choose to buy items and make their own meal or put their money together to make a nicer meal for the group. Make a weekly meal menu for the home and list all the ingredients needed to prepare the meal. Go to the store and look at prices and combinations of food items to see if there are ways to lower expenses or utilize ingredients in several meals. If youth are unable to go to a public grocery store, have them create the menu and list ingredients needed. They can then look in newspaper ads or on-line to get ideas about how much the meals may cost to prepare. 6/17/2010 Taking Training on Meals to the Next Level: An ideal way to teach about food preparation, meals and etiquette is to do so in a simulated (or real) kitchen and dining room. Some RTCs have life skills buildings that contain kitchen and dining areas that include all of the standard cooking appliances and supplies needed to prepare a meal as well as all of the serving ware needed to appropriately set the dining table for a nice meal. In addition to learning about cooking, nutrition, and meal planning, youth also can be taught dining etiquette. If your RTC is unable to provide these facilities, think about other ways that etiquette and other lessons could be taught. HOUSEKEEPING Laundry: If laundry facilities are available onsite that youth may use, teach the youth how to do laundry and give them the responsibility of taking care of their own laundry. One way to do this is for each youth to have an assigned laundry day. On that day, staff assist the youth with doing their laundry to the extent that each youth needs assistance. With youth who are just beginning to do laundry, who have never received formal instruction, or who need more supervision, staff should guide youth completely through the laundry process, teaching them how to sort clothes, appropriately fill the washer, use detergent, etc. The youth should also be taught how to put their clothes away after they have been cleaned, folding or hanging as appropriate to the type of apparel. As youth become more competent in their laundry skills, they can have more autonomy in doing the laundry with less and less assistance from staff. If the RTC does not have a laundry room onsite that youth can use, youth can be taken on an outing to a Laundromat to learn how to do laundry. Cleaning: In most RTCs, youth are given responsibility for making their own beds and helping to clean their living environment, such as sweeping and cleaning the bathroom. However, if this is not happening, it may be a good idea to incorporate such chores into the routine so that youth develop skills in housekeeping and learn to take responsibility for the cleanliness of their home. Organization: Youth often need to be taught how to keep their possessions in a neat and organized manner. This skill can best be taught one-on-one with the youth and a staff person, intern or volunteer. This person can help the youth sort through their possessions and organize them in their closet and other storage spaces. It is important to ensure that this experience is a learning opportunity for the youth, teaching them how to think through how to organize, rather than the assistant just doing the organizing for the youth. During this process, the assistant can aid the youth in determining that some items are no longer of use and should be gotten rid of, thus developing an important skill in managing one’s possessions. However, considering the particular situation of youth in foster care, it is not uncommon for youth to have a strong attachment to their possessions and have great difficulty in parting with them. Youth can be taught how to appropriately care for items of sentimental value by giving 6/17/2010 them the opportunity to put such items in an album or treasure chest. This can also make for a good therapeutic activity. FINANCIAL MANAGEMENT Allowances: If youth receive an allowance, create a log for keeping track of their money and have them write down any they spend. This will help prepare them for using a checkbook register and help them learn to manage their money. Responsible Spending: Create posters or pictures of household items, hygiene items, luxury items, and other necessities with prices attached. Have youth “go shopping” with a limited amount of money. You can even use Monopoly money for fun. Someone can play “cashier” to learn about making change. Youth can learn about the differences between “wants” and “needs” and how to prioritize certain items. Discuss fine tuning shopping experiences, such as making lists before you go and/or how to utilize coupons. Budgeting: Utilize mock check books and mock monthly budgets to help youth understand how to keep track of income and expenditures. Youth can prepare a budget for when they live on their own by giving them information about average wages for starting out jobs and the average costs of typical budget items, such as rent, utilities, cell phone bills, food, car insurance, child care, etc. Youth can even help find information about wages and costs by looking at advertisements and other publications and by asking adults who are willing to share the information. Banking: Teach about different types of bank accounts and the difference between debit and credit. Teach youth how to choose a bank and how to open checking and savings accounts. If appropriate and allowable, have youth open an account. Credit Cards: Bring in examples of credit card applications, and go over the “fine print.” Help youth calculate interest charges and other fees. Taxes: Bring in mock W-2 forms and 1040EZ forms, and show youth how to complete and file simple federal income taxes using the paper forms or online. Inform youth of community agencies where they can receive free assistance in completing their taxes. EMPLOYMENT Job Applications: Provide youth with the opportunity to practice filling out job applications. You can create a mock application or pick up some real applications from businesses for them to practice filling out. Interviews: Create role-plays of mock interviews. Allow youth to dress up for the “interview” and make mock follow up contacts to potential employers. 6/17/2010 On-the-Job Skills: Role-play difficult situations with customers or managers and how to maintain appropriate interactions. Teach basic job maintenance skills such as being on time, calling if you are going to be late, and giving notice if you intend to terminate. Resumes: Assist youth in making a resume. Word processing software, such as Microsoft Word, includes resume templates that make formatting a resume easy. There are also many resources available online to help in creating a resume. PERSONAL DEVELOPMENT Time Management: Youth can be taught how to prioritize the activities that they need to do and how to make a schedule for their day. They can also be taught how to utilize a calendar or planner to help them plan ahead. These skills can be taught as a group activity or one-on-one. Leadership Skills: A great way for youth to develop their leadership skills and to feel that they are able to have a voice in the RTC is to have a Residents’ Council. Criteria should be established to determine eligibility for participation in the council, and there should be policies outlining lengths of council terms, participation expectations, how council members input will be utilized and other important information. Peer Mentoring: A peer mentoring program can be implemented at the RTC in order to help youth build their leadership skills and feel that they are being of help to others while also providing an opportunity for residents to receive additional attention and support. Guidelines should be established to determine eligibility to be a peer mentor and to outline the peer mentor’s roles and responsibilities, such as ensuring that peer mentors report to staff if their mentee has informed them of any safety-related issues. SOME MORE TIPS Have youth apply for a library card and learn how to borrow books from the library. Have youth complete training in First Aid and CPR. Have youth take a driver’s education class. If appropriate, allow and encourage youth to get part-time jobs. If they are unable to leave the RTC campus, perhaps jobs could be made available on campus. Please note that these activities are just some suggestions to get you started on your journey of providing experiential life skills activities to youth in your care. The list is not comprehensive, and caregivers are not required by DFPS to provide these specific experiential activities. If you 6/17/2010 have ideas for other experiential activities or tips to include on this list, please contact DFPS at [email protected]. 6/17/2010 Resources to Aid Caregivers in Providing Experiential Life Skills Training to Foster Youth The resources listed below are just some suggestions to get you started on your journey of providing experiential life skills activities to youth in your care. This list is a product of the House Bill 1912 (81st Legislative Session) workgroup and were developed to help caregivers fulfill the requirement of providing or assisting foster youth age 14 or older in obtaining experiential life-skills training to improve their transition to independent living. This list is not comprehensive, and caregivers are not required by DFPS to use any of these resources. The materials referenced below contain information created and maintained by other government, public and private organizations and are provided for the user's convenience. i If you have ideas for other materials to include on this list, please contact DFPS at [email protected] . Life Skills Training Resources Texas Youth Connection web site: http://www.dfps.state.tx.us/txyouth/default.asp DFPS Transitional Living Services Information http://www.dfps.state.tx.us/Child_Protection/Transitional_Living/default.asp Ready, Set, Fly! A Parent’s Guide to Teaching Life Skills by Casey Family Programs - Available in print and also online at http://www.caseylifeskills.org/pages/res/rsf%5CRSF.pdf) Casey Family Programs list of free web resources: http://www.caseylifeskills.org/pages/res/res_ACLSAGuidebook.htm#5 Casey Family Programs comprehensive list of resources, including those available for purchase: http://www.caseylifeskills.org/pages/res/res_ACLSAGuidebook.htm “50 Things You Can Do to Help Someone Get Ready for Independent Living” http://www.hss.alaska.gov/ocs/IndependentLiving/Docs/RS%2050%20Things.pdf “Life Skills Inventory: Independent Living Skills Assessment Tool” http://www.dshs.wa.gov/pdf/ms/forms/10_267.pdf Independent Living Books and DVDs by Social Learning http://www.sociallearning.com/catalog/topics/lifeskills/independentliving.html;jsessionid=a8boZGg48se5 “Truth About Drugs” DVD http://store.discoveryeducation.com/product/show/51960 “Truth About Drinking” DVD http://store.discoveryeducation.com/product/show/53563 6/17/2010 1 “Truth About Sex” DVD http://store.discoveryeducation.com/product/show/48582 FosterClub http://www.fosterclub.com/ Retailers of Life Skills Training Resources National Resource Center of Youth Services http://www.nrcys.ou.edu/catalog/ National Independent Living Association http://www.nilausa.org/membersonly/memresourcesn.htm Daniel Memorial http://www.danielkids.org/sites/web/store/product.cfm Youth Communication http://www.youthcomm.org/ Social Learning http://www.sociallearning.com/ Discovery Education http://www.discoveryeducation.com/ Training for Caregivers “Teaching Moments: How Foster Parents Can Teach Independent Living Skills To Teens” DVD http://www.sociallearning.com/catalog/items/DVD7316.html;jsessionid=adIWbottIDV9 Foster Care and Adoptive Community Training: http://www.fosterparentstest.com/store/index.htm “Teaching Essential Life Skills to Children of All Ages” “Teaching Independence & Keeping Fragile Kids Safe” “Preparing for Post High School Education” “Enhancing Independence Through Recognizing and Improving Job Skills” “Money Skills” “Sexually Transmitted Diseases: What You Need To Know” “Health Issues” i DFPS does not control or guarantee the accuracy, relevance, timeliness or completeness of this outside information. Further, the inclusion of references to particular materials and/or of links to particular organizations or sites is not intended to reflect their importance, nor is it intended to endorse any views expressed, or products or services offered on these outside sites, or the organizations sponsoring the sites. 6/17/2010 2 Printer-friendly version Print using your browser ‘Print’ button << Click the browser ‘Close’ button to move on Module III. Unit 1: Activity 3 – Making Contact with the School A Tip Sheet for Effective Educational Advocacy Things to consider doing: 1. Initiate contact with the education provider starting at the “top.” It is considered common courtesy in the education community for “outsiders” to initiate telephone contact with the principal first. (This was addressed in Module II.) 2. Always wear a photo ID badge or carry a photo ID to present at the school or agency office, AND always check in at the office. 3. Be prepared to present the Order of Appointment from the court. 4. Be prepared to explain the role of a CASA/GAL volunteer. It may be important to explain your role several times to several educators in the process (principal, teacher, social worker, school psychologist, at special education team meetings, etc.). It might be helpful to carry some brochures. 5. Think of the time of day you might contact a teacher. Ask him or her what is convenient and whether he or she prefers to be contacted by phone or e-mail. Teachers have responsibilities beyond the classroom, i.e., lunch duty, committee meetings, etc. 6. Tap into other resources within the school, which include school social worker, school counselor, and school psychologist. 7. Ask if the parent(s)/guardian(s) are involved in educational decision-making, and, if not, advocate for the child to be assigned an educational surrogate/advocate. 8. Get to know the school personnel on a friendly basis. Allow the school to consider the CASA/GAL volunteer as a resource who is interested in the child. Be personable! When you present yourself in a professional and easygoing manner, opportunities for collaboration will be greater. 9. Check in with teachers regularly, not just when there’s a problem or when there is an upcoming meeting. National CASA E-Learning – 11.05 10. Let the school know you are interested in this student and will follow up on important issues. 11. Go over old school reports and assessments. Ask questions where you need clarification. If a child was in another school for a long period of time (perhaps before going into foster care), make contact with that school and request records and information. 12. If a problem arises, always ask for and listen to the school’s side of the issue. 13. Request that the school notify you in advance so that you may attend meetings applicable to the child (team meetings, IEP meetings, etc.). 14. Discuss the child’s educational status with the child’s caseworker and include this information in your court report. 15. Ask the child how he or she is doing in school and include that information in your court report. 16. Note if behavior difficulties at school can be correlated with other issues in the child’s life. 17. Facilitate communication to best serve the child within the context of your volunteer role. Things to consider avoiding: 1. Making “You should…” types of statements to education providers. 2. Becoming too adversarial. Don’t make meetings seem too much like a legal proceeding. 3. Badmouthing the child’s family or home situation. Rise above the temptation to join in with such gossip, even if you hear others doing it. 4. Sharing information you get from one education source with another education source, even within the same building. For example, the school psychologist or counselor may share information with the CASA/GAL National CASA E-Learning – 11.05 volunteer that is not to be shared with the teacher. If such confidentialities are breached, it will be difficult to enlist friendly cooperation in the future. However, your sources should be aware that a CASA/GAL volunteer cannot keep secrets from the court. 5. Signing papers in the school setting regarding the child, such as medical status, permission to test, or school transfers. That is the job of the parent/guardian or educational surrogate/advocate. However, you may be asked to sign forms indicating attendance at some school meetings. 6. Making educational recommendations that don’t fit with recommendations of the education team at school (especially as related to special education). 7. Dropping in at the school. Always call in advance to request an appointment or, at the very least, to notify the staff that you will be visiting. Source: Washington State CASA and TeamChild® National CASA E-Learning – 11.05 Printer-friendly version Print using your browser 'Print' button << Click the browser 'Close' button to move on Module IV. Unit 3: Activity 4 – Asking the Right Questions: A Judicial Checklist To Ensure That the Educational Needs of Children and Youth in Foster Care Are Being Addressed General Education Information Enrollment Is the child or youth enrolled in school? o At which school is the child or youth enrolled? o In what type of school setting is the child or youth enrolled (e.g., specialized school)? How long has the child or youth been attending his/her current school? o Where is this school located in relation to the child’s or youth’s foster care placement? Were efforts made to continue school placement, where feasible? If currently not in a school setting, what educational services is the child or youth receiving and from whom? o Is the child or youth receiving homebound or home-schooled educational services? o If Yes: Who is responsible for providing educational materials and what information is available about their quality? o If Yes: How frequently are educational sessions taking place? o What is the duration of each session (e.g., how many hours)? Provision of Supplies Does the child or youth have appropriate clothing to attend school? Does the child or youth have the necessary supplies and equipment (e.g., pens, notebooks, musical instrument) to be successful in school? Transportation How is the child or youth getting to and from school? What entity (e.g., school, child welfare agency) is responsible for providing transportation? Attendance Is the child or youth regularly attending school? Has the child or youth been expelled, suspended, or excluded from school this year/ever? o If Yes: How many times? o Have proper due process procedures been followed for the expulsions, suspensions, or exclusions from school? National CASA E-Learning 11.05 What was the nature/reason for the child’s or youth’s most recent expulsion, suspension, or exclusion from school? o How many days of school will the child or youth miss as a result of being expelled, suspended, or excluded from school? o If currently not attending school, what educational services is the child or youth receiving and from whom? How many days of school has the child or youth missed this year? o What is the reason for these absences? o What steps have been taken to address these absences? o Has the child or youth received any truancies, and, if so, for how many days? o Has the child or youth been tardy, and, if so, how many times? o Performance Level When did the child or youth last receive an educational evaluation or assessment? o How current is this educational evaluation or assessment? o How comprehensive is this assessment? At which grade level is this child or youth currently performing? (Is the child or youth academically on target?) o Is this the appropriate grade level at which the child or youth should be functioning? o If No: What is the appropriate grade level for this child or youth? Is there a specified plan in place to help this child or youth reach that level? What is this child’s or youth’s current grade point average? o If below average, what efforts are being made to address this issue? Is the child or youth receiving any tutoring or other academic supportive services? o If Yes: In which subjects? Tracking Education Information Does this child or youth have a responsible adult serving as an educational advocate? o If Yes: Who is this adult? o How long has this adult been advocating for the child’s or youth’s educational needs? o How often does this adult meet with the child or youth? o Does this adult attend scheduled meetings on behalf of the child or youth? o Is this adult effective as an advocate? If there is no designated educational advocate, who ensures that the child’s or youth’s educational needs are being met? o Who is making sure that the child or youth is attending school? o Who gathers and communicates information about the child’s or youth’s educational history and needs? o Who is responsible for educational decision-making for the child or youth? National CASA E-Learning 11.05 Who monitors the child’s or youth’s educational progress on an ongoing basis? Who is notified by the school if the child or youth is absent (i.e., foster parent, caseworker)? Who could be appointed to advocate on behalf of the child or youth if his or her educational needs are not met? o Change in Placement/Change in School Has the child or youth experienced a change in schools as a result of a change in his or her foster care placement? o If Yes: How many times has this occurred? o What information, if any, has been provided to the child’s or youth’s new school about his or her needs? o Did this change in foster care placement result in the child or youth missing any school? o If Yes: How many days of school did the child or youth miss? Have any of these absences resulted in a truancy petition? o Were efforts made to maintain the child or youth in his or her original school despite foster care placement change? Health Factors Impacting Education Physical Health Does the child or youth have any physical issues that impair his or her ability to learn, interact appropriately, or attend school regularly (e.g., hearing impairment, visual impairment)? o If Yes: What is this physical issue? How is this physical issue impacting the child’s or youth’s education? How is this need being addressed? Mental Health Does the child or youth have any mental health issues that impair his or her ability to learn, interact appropriately, or attend school regularly? o If Yes: What is this mental health issue? How is this mental health issue impacting the child’s or youth’s education? How is this need being addressed? Is the child or youth currently being prescribed any psychotropic medications? o If Yes: Which medications have been prescribed? Has the need for the child or youth to be taking this medication been clearly and directly explained to him or her? How will this medication affect the child’s or youth’s educational experience? National CASA E-Learning 11.05 Emotional Issues Does the child or youth have any emotional issues that impair his or her ability to learn, interact appropriately, or attend school regularly? o If Yes: What is this emotional issue? How is this emotional issue impacting the child’s or youth’s education? How is this need being addressed? Is the child or youth experiencing any difficulty interacting with other children or youth at school? (E.g., Does the child or youth have a network of friends? Has he or she experienced any difficulty with bullying?) o If Yes: What is being done to address this issue? Special Education and Related Services Under IDEA and Section 504 If the child or youth has a physical, mental health, or emotional disability that impacts learning, has this child or youth (birth to age 21) been evaluated for Special Education/Section 504 eligibility and services? o If No: Who will make a referral for evaluation or assessment? o If Yes: What are the results of such an assessment? o Have the assessment results been shared with the appropriate individuals at the school? Does the child or youth have an appointed surrogate pursuant to IDEA (e.g., child’s or youth’s birth parent, someone else meeting the IDEA definition of parent, or an appointed surrogate parent)? o If No: Who is the person that can best speak on behalf of the educational needs of the child or youth? o Has the court used its authority to appoint a surrogate for the child or youth? o Has the child’s or youth’s education decision-maker been informed of all information in the assessment, and does that individual understand the results? Does this child or youth have an individualized education plan (IEP)? o If Yes: Is the child’s or youth’s parent or caretaker cooperating in giving IEP information to the appropriate stakeholders or signing releases? o Is this plan meeting the child’s or youth’s needs? o Is the child’s or youth’s educational decision-maker fully participating in developing the IEP, and do they agree with the plan? Does this child or youth have a Section 504 plan? o If Yes: Is this plan meeting his or her needs? o Is there an advocate for the child or youth participating in meetings and development of this plan? Extracurricular Activities and Talents What are some identifiable areas in which the child or youth is excelling at school? Is this child or youth involved in any extracurricular activities? o If Yes: Which activities is the child or youth involved in? National CASA E-Learning 11.05 Are efforts being made to allow this child or youth to continue in his or her extracurricular activities (e.g., provision of transportation, additional equipment, etc.)? Have any of the child’s or youth’s talents been identified? o If Yes: What are these talents? What efforts are being made to encourage the child or youth to pursue these talents? o Transitioning Does the youth have an independent living plan? o If Yes: Did the youth participate in developing this plan? Does this plan reflect the youth’s goals? o If Yes: Does the plan include participation in Chafee independent living services? Does this plan include vocational or post-secondary educational goals and preparation for the youth? Is the youth receiving assistance in applying for post-secondary schooling or vocational training? Is the youth being provided with information and assistance in applying for financial aid, including federally funded Educational and Training Vouchers (see Chafee Foster Care Independence Program)? If the youth has an IEP, does it address transition issues? o If Yes: What does this transition plan entail? o Did the youth participate in developing the transition plan? o Is this transition plan coordinated with the youth’s independent living plan? Practice Tip: When appropriate, consider addressing these questions directly to the children and youth. From National Council of Juvenile and Family Court Judges, Casey Family Programs, and TeamChild®, www.ncjfcj.org. National CASA E-Learning 11.05 TIPS FOR CHILD ADVOCATES 1. Choose your issue. There will be many aspects of the child welfare system that are not working most efficiently or effectively for the child. The child will also have multiple issues/needs. Our recommendations may have to look at resolutions that are not ideal. As the advocate, you must prioritize and weight what is MOST needed and important. 2. Identify solutions. Never pose the problems without also having identified some solutions to give the court recommendations about positive action that can be taken on behalf of the child’s best interest. 3. Identify supporters/resources. In identifying solutions, look for community resources for the child, for the family, for potential caretakers. Look for adult connections, mentors, support groups and extracurricular activities that will benefit the child. 4. Develop a strategy. How will you advocate for positive outcomes for the child in their current placement?, with regard to permanency?, within the child welfare system at the local level?, within the state system? Continue to gather information with an open mind that allows for recommendations and strategies to change. 5. Frame your message. Communication with the court and other professionals is a key element of advocacy. Using neutral, objective language will further recommendations. Empathy and a non-defensive posture will demonstrate your trustworthiness. Write effective court reports and give credible testimony. 6. Educate. Build bridges with all service providers and take the opportunity to constantly educate the system about the CASA role. 7. Testify. Find the balance between assertive advocacy and open minded receptivity to new information and an alternate plan. Speak with authority gained through the work done. Also, offer to tell your story at a public hearing. The personal experiences of constituents are very powerful in convincing government officials to make changes. 8. Don't give up! Persistence, persistence, persistence. The child welfare system can be a difficult arena in which to effect change. When a promising plan falls apart, it can be hard to rally and start again. Remember, the child is depending on you and your strength of conviction to pursue a hopeful future for them. Advocating for Your Child: 25 Tips for Parents Written by David Fassler, M.D. Child & Adolescent Psychiatrist According to the Surgeon General, 1 child in 5 experiences significant problems due to a psychiatric disorder. The good news is that we can help many, if not most, of these youngsters. The real tragedy is that so few, less than 1 in 3, are receiving the comprehensive treatment they really need. Children and adolescents with emotional and behavioral problems deserve access to the best possible mental health care. Unfortunately, such services are often difficult to obtain. Parents can help by being informed, involved and persistent advocates on behalf of their children. The following outline offers specific tips and suggestions, which parents may find useful in such advocacy efforts. Individual advocacy for your own child: 1. Get a comprehensive evaluation. Child psychiatric disorders are complex and at times confusing. A full assessment often involves several visits. Effective treatment depends on a careful and accurate diagnosis. 2. Insist on the best. Talk to physicians, therapists, guidance counselors and other parents. Find out who in your community has the most experience and expertise in evaluating and treating your child’s particular condition. Check the clinician’s credentials carefully. Are they appropriately licensed or certified in your state? If he or she is a physician, are they “Board Certified”? Push schools, insurance companies and state agencies to provide the most appropriate and best possible services, not merely services that are deemed sufficient or adequate. 3. Ask lots of questions about any diagnosis or proposed treatment. Encourage your child to ask any questions he or she may have, as well. Remember that no one has all the answers, and that there are few simple solutions for complex child psychiatric disorders. In addition, all treatments have both risks and benefits. Make sure you and your child understand the full range of treatment options available so you can make a truly informed decision. Fassler Resource -1- 2003 4. Insist on care that is “family centered” and builds on your child’s strengths. Ask about specific goals and objectives. How will you know if treatment is helping? If your child’s problems persist or worsen, what options and alternatives are available? 5. Ask about comprehensive “wrap around” or individualized services, geared specifically to the needs of your child and family. Are such services available in your state or community? If not, why not? 6. Be prepared. One of the most important things you can do to help your child is to keep all information, including past consultation and treatment reports, in an organized place. Insist on receiving your own copies of all evaluations. Records can easily be misplaced, delayed or even destroyed. Maintaining your own file with all relevant information can help avoid unnecessary duplication of previous treatment efforts. 7. Feel free to seek a second opinion. Any responsible mental health professional will be glad to help with referrals or by sharing information. If you have questions about your child’s diagnosis or the proposed course of treatment, by all means, arrange an independent consultation with another clinician. 8. Help your child learn about their condition. Use books, pamphlets and the Internet. Make sure the information is age appropriate. Answer questions with honest, accurate and consistent information, but don’t overload children with more detail than they want or need. 9. Know the details of your insurance policy, and learn about the laws governing insurance in your state. For example, in some states, insurance companies must provide access to a specialist, such as a child and adolescent psychiatrist, within a certain distance from your home. If no such specialist is available as part of the company’s “network”, you may be able to receive treatment from a provider of your choice, with the insurance company responsible for full payment. 10. Work with the schools. Insist on access to appropriate mental health consultation services. You can also suggest inservice training programs to enhance awareness about child psychiatric disorders. Request copies of your child’s educational records, including the results of any formal testing or other evaluations. Ask to be included in any and all school meetings held to discuss your child. 11. Learn about the reimbursement and funding systems in your state. The more you know, the better you can advocate on behalf of your child. How does Medicaid work? Which services are covered and which are excluded? Is there a Medicaid “waiver program” which allows increased flexibility based on the specific needs of children and families? Is your child eligible? If not, why not? What other sources of funding are potentially available? Fassler Resource -2- 2003 12. If necessary, use a lawyer. Learn about the local legal resources. Find out which lawyers in your community are familiar with educational and mental health issues. Talk to your local Protection and Advocacy agency or American Civil Liberties Union for suggestions. Call the State Bar Association. Talk to other parents who are lawyers or who have used lawyers. Consider a legal consultation to make sure you are pursuing all appropriate avenues and options regarding services for your child. Statewide advocacy for all children, including your own: 13. Become politically active. Meet with state senators and representatives. Question candidates about their positions on access to necessary and appropriate mental health services for children and families. Testify at hearings on state legislation and budgets. Legislators are more likely to be influenced and persuaded by personal stories than by data, statistics or the opinions of professionals. 14. Get to know the state insurance commissioner and healthcare “ombudsperson” or consumer representative. Ask them to attend regular meetings with parent groups. Let them know about your experiences. 15. Build coalitions and work with local advocacy and parent organizations such as the National Alliance for the Mentally Ill (NAMI), the National Mental Health Association (NMHA) and the Federation of Families for Children’s Mental Health . Develop and publicize a common “Agenda for Children’s Mental Health”. 16. Teach children about advocacy. Invite them to become involved in advocacy activities, where appropriate, but don’t force them to participate. 17. Develop a legislative strategy. If your state does not yet have parity legislation, put this at the top of the agenda. Other “family protection” initiatives include: • • • • • access to an independent panel to review and potentially reverse insurance company denials consumer representation on community mental health center boards adequate network provisions, which mandate timely and appropriate access to specialists adequate funding for school and community-based mental health services interagency collaboration for children who are involved with more than one system (i.e., child welfare, mental health, education and juvenile justice). 18. Seek bipartisan support. Mental illness affects families of all political persuasions. Building a broad base of support has been a key to successful legislative initiatives, both at the State and Federal levels. 19. Fight stigma. Develop an ongoing local education campaign that reiterates the key messages: Fassler Resource -3- 2003 • • • child psychiatric disorders are very real illnesses they affect lots of kids and adolescents fortunately, they are also treatable, especially if treatment begins early and is individualized to the needs of each child and family. 20. Become involved with medical education. Meet with local medical students and residents. Sensitize them to the issues and challenges families face when caring for a child with emotional and behavioral problems. 21. Use the media. Write letters to the editor and/or op-ed pieces on child mental health issues. Meet with local reporters covering health care topics. Suggest story ideas to local TV stations. 22. Work with local professional organizations. Psychiatrists, psychologists, social workers, psychiatric nurses, and mental health counselors are natural allies with a common advocacy agenda. Coordinate efforts on issues such as parity, funding for mental health services, managed care oversight, etc. Professional organizations may also have access to resources, including funds for lobbying and/or public education initiatives, from their national associations. 23. Talk to other parents. Seek out and join local parent support groups. If none exist, consider starting one. Develop an email “listserv” to facilitate communication. Circulate articles, information and suggestions about local resources. 24. Attend regional and national conferences of parent and advocacy organizations. Such meetings provide information, ideas, camaraderie and support. Sharing experiences with other parents is both helpful and empowering. 25. Don’t give up. Aim for and celebrate incremental victories and accomplishments. Remember, advocacy is an ongoing process! There’s no right or wrong way to be an advocate for your child. Advocacy efforts and initiatives should be individualized to your state, community and the particular issues, circumstances and needs within your family. Advocacy is also hard work. Even when people want to help, and are willing to listen, it takes lots of time and energy to change the system. But when it works, and it often does, the outcome is clearly worthwhile. You really can make a difference, both for your own child, and ultimately for all children who need and deserve access to appropriate and effective mental health treatment services. Fassler Resource -4- 2003 Module II. Unit 4: Activity 2 - Quick Reference Grid on Information Sharing Printer-friendly version Print using your browser ‘Print’ button << Click the browser ‘Close’ button to move on Can share all information with Child Welfare. Can share information related to educational needs of child. Dictated by Child Welfare licensing contracts and individual care plans. This includes information necessary to provide adequate care for the child. National CASA E-Learning 11.05 Source: Field Guide for Information Sharing, WA State DSHS, WA State OSPI, Casey Family Programs, Treehouse, TeamChild, and Washington State CASA. 10/04 1. They can facilitate the sharing of information between other parties. In addition, they may disclose information to perform duties assigned by the court, such as advocacy. When in doubt about what and with whom to share, discuss with your supervisor. 2. The best practice is for caregivers to get written consent for information sharing, signed by the caseworker assigned to the child. School staff and educators are allowed to discuss with others their personal observations about a child. 3. “Caregiver” means person with whom the child lives as a result of placement by the court or Child Welfare. Foster Placement, Relative, Licensed Caregiver (See 3.) CASA/GAL volunteers may only disclose information to the court or to others allowed by court order. (See 1.) CASA/GAL Volunteer Caregivers to get written consent, signed by caseworker assigned to child. School may discuss personal observations. (See 2.) May discuss personal observations. Schools must release educational records to CASA/GAL volunteers. Follow protocols for requesting records. Schools must release educational records to biological parents unless a court order limits parental access. Enrolling district must request student records from the prior district. Schools can release info to Child Welfare in emergency, under court order, subpoena, and when child is in dependent or shelter care. School Staff and Educators Retains control over information and can share with others, unless limited by a court order. Caseworkers share information with caregivers necessary for case planning. Caseworkers share everything with CASA/GAL volunteers. Caseworkers share all information with very few exceptions. Caseworkers can share information necessary for case planning. Caseworkers can share all information within their system. Child Welfare System Parent or Legal Custodian Foster Placement, Relative, Licensed Caregiver CASA/GAL Volunteer Parent or Legal Custodian School Staff and Educators Child Welfare System RECEIVERS OF INFORMATION Review the following grid, which details what key givers and receivers of information can share. Some information may be specific to Washington State laws and not applicable in other states. Ask your supervisor and note any questions you may have. GIVERS OF INFORMATION
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